8.HACEMOS LO QUE SABEMOS HACEMOS LO QUE DECIMOS ???
8.1. NATURALEZA DEL PROYECTO
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2C-‐4 APPLY MEDICAL NECESSITY RULES IN AUDIT ACTIVITY
Understanding medical necessity rules is a critical component of coding and billing compliance. In order for admissions to be considered medically necessary, the patient must have a condition requiring treatment that can be provided only in an inpatient setting. If the patient safely can receive treatment in a less intensive setting, such as outpatient observation, the patient should not be admitted. Medical Necessity must be:
• Consistent with the symptoms or diagnoses of the illness or injury under treatment. • Necessary and consistent with generally accepted professional medical standards (i.e., not
experimental or investigational).
• Not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier.
• Furnished at the most appropriate level that can be provided safely and effectively to the patient.
Approximately 40 percent of all improper payments identified during the three-‐year RAC demonstration project stemmed from medical necessity; for inpatient hospitals, a whopping 62 percent of
overpayments were the result of "errors in the determination of medical necessity." The revenue impact of these denials was $513 million in just three states. (RACmonitor.com Aug 11, 2010)
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-‐based process, with opportunities for public participation. In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD). LCD’s are made through local FI’s (fiscal intermediaries).
The Medicare Coverage Database contains all National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) and can be accessed at http://www.cms.gov/medicare-‐coverage-‐ database/.
There are several commercial products available to help in determining medical necessity. Interqual and Milliman are two of the most widely used. These products list specific criteria that a patient must meet in order for a hospital admission to be deemed appropriate and necessary. 90
2C-‐5 APPLY UTILIZATION REVIEW CRITERIA & PROTOCOLS IN MEDICAL AUDIT ACTIVITY The utilization review process compares requests for medical services ("utilization") to treatment guidelines that are deemed appropriate for such services and includes the preparation of a recommendation based on that comparison.
Definitions Utilization Review
The process of comparing requests for medical services (“utilization”) to guidelines or criteria that are deemed appropriate for such services, and making a recommendation based on that comparison. Prospective Review
Those conducted prior to the delivery of the services requested. Prospective reviews may be for inpatient or outpatient services. The list of services varies, but most lists include nonemergency
hospitalizations, outpatient surgery, 91 skilled nursing and rehabilitation services, home care services and
some home medical equipment. The review and approval involves determining whether the requested service is medically necessary.
90 This section submitted by Patricia Barryessa, CMAS
There are usually predetermined criteria or clinical guidelines of care for a given condition. The process begins with the collection of information, including the symptoms, diagnosis, results of any lab tests and list of required services. The reviewer then reviews the criteria for the condition.
Concurrent Review
Concurrent reviews happen during active management of a condition. An important part of concurrent review is the assessment of the patient's needs after a hospitalization. Because concurrent review is used to decrease the amount of time you spend in the hospital, the first concurrent review often determines a discharge plan. This plan can include transfers to rehabilitation, hospice or nursing facilities.
Retrospective Review
Retrospective review involves the review of medical records after the medical treatment. The reviewer looks the medical records for evidence of medically necessary health care.
Utilization review is generally done by a nurse who has experience using criteria sets to determine if a service is medically necessary. For instance, in reviewing a preauthorization request for an ACL repair (Anterior cruciate ligament), one might use the following as part of the criteria determine whether surgery is appropriate at this time:
1. What conservative measures have been tried (i.e.…physical therapy, wearing a brace)
2. Is the knee unstable or buckling? Was there significant swelling at the time of injury? Does the patient describe a twisting or hyperextension at the time of the injury?
3. MRI demonstrates an ACL disruption 4. Pain is not controlled by NSAIDS.
If the patient meets all of the above, the nurse reviewer could determine that this is a medically necessary surgery at this point in the care of this patient. At any point, the nurse has the option to request additional medical records for review. 92
2C-‐6 APPLY CODING RULES IN MEDICAL AUDIT ACTIVITY
Clinical Coding is "the translation of medical terminology as written by the clinician to describe a
patient's complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format" which is nationally and internationally recognized.
Coding audits should be done on a routine basis; most HIM departments have protocols they follow. Code audits are done by the coders, however, it is important that the auditor be aware of these because it plays such a significant part in the billing accuracy. This does several things:
• Verifies that coding is consistent and accurate • Gives confidence to reviewers of accuracy • Maintains effective Quality Improvement
Auditors do not commonly audit for DRG assignment (this is usually done by a coder), but it is valuable to understand what the process looks like. These codes do directly affect all aspects whether it is charge audit or DRG. If claims are paid by DRG for a particular provider (inpatient), these same codes may affect those patients that are outpatient for that same provider. And know they will affect some provider at some time for sure.
When the auditor reviews a medical record, they should be able to verify that the coding submitted to the payer is correct. These codes are used by the payer to establish many things. They are used for payment as well as case management of the patient care in many cases.
Medical coders also establish many other "codes" that are assigned to the claim, the UB-‐04. Each one of the fields on the UB represents something that someone wants to know or track. It is important to know what these fields represent. These fields tell a great deal about the patient, and the provider. They link dates of service with diagnosis as well as services provided. The claim tells a story. In healthcare it is becoming more and more important to tell a more detailed story each time a patient comes into contact with a provider. When all the codes are correct and the patient’s story is complete, a clean claim is submitted, and in most cases an expedited payment is received.
Additional information regarding the UB-‐04 and field locator is presented in 2B-‐5. 93
The OIG offers examples as well in their reports and findings as well as compliance guidance. There are several examples provided at: http://www.va.gov/oig/54/reports/VAOIG-‐09-‐03418-‐68.pdf
2C-‐7 APPLY REGULATORY AND LEGISLATIVE POLICIES IN MEDICAL AUDIT ACTIVITY
Regulatory and legislative policies govern Medicare and Medicaid compliance and reimbursement. The legislative policies that would be of most relevance in an audit are the eligibility, coverage, compliance and medical necessity policies. Eligibility will be covered by the Social Security Act, 42 CFR or Medicare / Medicaid Policies. Eligibility should be the first step in an audit. This is because if the patient was not eligible for coverage then the rest of the audit is moot. Most hospitals and physicians offices have on-‐ line eligibility software. Alternatively some private payers also allow for eligibility checking on their websites. No matter how this is achieved the regulations provide methods to determine eligibility.
Other aspects of the regulations include coverage and compliance. These regulations are located within the CMS manuals. These filters down from the Social Security Act, 42 CFR to the transmittals and finally the manuals.
Manuals can be found at: www.cms.gov/manuals
While the Internet-‐Only Manuals (IOMs) contain the majority of current regulations, older regulations are still found within the Paper-‐Based Manuals. The IOMs all begin with publication 100 and then each manual has its own individual secondary identifier number. The majority of audit requirements are found within the Medicare Benefit Policy Manual (100-‐02) and Medicare Claims Processing Manual (100-‐04).
MEDICARE INTERNET ONLY MANUALS (IOMS)
The IOMs are as follow.
Publication # Title
100 Introduction
100-‐01
Medicare General Information, Eligibility and Entitlement Manual
100-‐02 Medicare Benefit Policy Manual
100-‐03 Medicare National Coverage Determinations (NCD) Manual
Publication # Title
100-‐05 Medicare Secondary Payer Manual
100-‐07 State Operations Manual
100-‐08 Medicare Program Integrity Manual
100-‐09
Medicare Contractor Beneficiary and Provider Communications Manual
100-‐10 Quality Improvement Organization Manual
100-‐11 Reserved
100-‐12
State Medicaid Manual (The new manual is under development. Please continue to use the Paper-‐Based Manual to make your selection.)
100-‐13
Medicaid State Children's Health Insurance Program (Under Development)
100-‐14 Medicare ESRD Network Organizations Manual
100-‐15 Reserved
100-‐16 Medicare Managed Care Manual
Publication # Title
100-‐18 Medicare Prescription Drug Benefit Manual
100-‐19 Demonstrations
100-‐20 One-‐Time Notification
100-‐21 Recurring Update Notification
100-‐22 Medicare Quality Reporting Incentive programs Manual
100-‐24 State Buy-‐In Manual
MEDICARE PAPER-‐BASED MANUALS
Older manuals can be located within the paper manual sections. The majority of these manuals date back to the time of cost based reimbursement. The paper-‐based manuals are as follow:
Publication # Title
06 Coverage Issues Manual
09 The Outpatient Physical Therapy/CORF Manual
10 The Hospital Manual
12 The Skilled Nursing Facility Manual
13 The Intermediary Manual
14 The Carriers Manual
15-‐1 The Provider Reimbursement Manual -‐ Part 1
15-‐2
The Provider Reimbursement Manual -‐ Part 2, Note: To comply with section 508, active cost report forms are furnished in two formats. Section 508 compliant format identified as files with a CSV extension, for the visually impaired and the standard Excel files for non-‐impaired users.
19 The Peer Review Organization Manual
21 The Hospice Manual
23
The Regional Office Manual (Available to CMS staff through TIMS)
27
The Medicare Rural Health Clinic and Federally Qualified Health Center Manual
29 The Medicare Renal Dialysis Facility Manual
45 The State Medicaid Manual
Within this grouping of manuals we find some very essential references such as the Hospital Manual (which has become the Benefit Policy and the Claims Processing Manual). Other regulations can be found in the instructions to the Fiscal Intermediary within the Intermediary Manual.
Many commercial payers follow Medicare and/or Medicaid guidelines. Therefore, when performing a commercial or managed care audit the contract must be reviewed to determine if the particular payer does follow these regulatory guidelines.
Finally, Medicare guidelines are also provided regionally by Medicare Administrative Contractors (MAC). They generally provide instructional guidance on claims management. They provide additional guidance on medical necessity. Medical necessity is covered more in depth within Core Domain 2C-‐4
2C-‐8 REPORT IDENTIFIED AND POTENTIAL QUALITY AND RISK MANAGEMENT ISSUES
During the auditor’s review of the record it is not uncommon to come across a pattern or behaviour or a singular event that should be reported to appropriate personnel. Risk / Quality management issues such as “never events” discovered within the record should be included within the final report as a tangential finding. Never events are defined by the National Quality Forum and can be found at: http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx. Examples are wrong surgery performed, wrong patient, wrong body part etc… Other risk management / quality issues can be nursing performing services without a valid physician order, physicians providing incomplete orders, failures to document procedures or services. The auditor may need to use their judgement to review the record and include in the report any areas where documentation did not support a service or demonstrated risk. Other areas of risk could be charges placed on the wrong account as the patient would have co-‐pay and or full liability for services not rendered and could be considered fraudulent charges. No matter what the inconsistency medical-‐legal issues should be included within the report to the client.
In some cases, audits are conducted under an attorney-‐client privileged engagement. In this case, the supervising attorney may direct the auditor to label the documents as “workproducts”. Disclosure of any findings can only be made directly to the attorney who will then share the products with his / her client.
2C-‐9 PARTICIPATE / CONDUCT INTER-‐RATER RELIABILITY (IRR) AND VALIDATION EXERCISES According to Wikipedia, Inter-‐rater reliability is defined as:
“In statistics, inter-‐rater reliability, inter-‐rater agreement, or concordance is the degree of agreement among raters. It gives a score of how much homogeneity, or consensus, there is in the ratings given by judges. It is useful in refining the tools given to human judges, for example
by determining if a particular scale is appropriate for measuring a particular variable. If various raters do not agree, either the scale is defective or the raters need to be re-‐trained.
There are a number of statistics that can be used to determine inter-‐rater reliability. Different statistics are appropriate for different types of measurement. Some options are: joint-‐probability of agreement, Cohen's kappa and the related Fleiss' kappa, inter-‐rater correlation, concordance correlation coefficient and intra-‐class correlation.”94
An example of how an audit is conducted using the inter-‐rater reliability concepts can be found at: • http://www.partnershiphp.org/provman/Sect-‐5/hs/UM/MPUP3026.pdf
An excerpt from that document and the relevance to healthcare auditing is detailed below.
95
Non-‐ financial audits also are examples utilising inter-‐rater reliability. Many examples of Quality audits can be found within National Health Service in the United Kingdom. One specific report can be found at:
• http://qualitysafety.bmj.com/content/19/5/1.17.full.pdf+html
2C-‐10 DEVELOP / UPDATE DATABASE FOR TRACKING AND TRENDING MEDICAL AUDIT FINDINGS
The US is in an “auditing” frenzy. There are federal audits like MAC, RAC, Medicaid RAC, and ZPIC’s. Additionally, there are commercial, third party administrator and quality audits being conducted by all types of payers. Developing a database for tracking and trending medical audit results is entirely dependent upon the deliverable and type of audit being undertaken. Facilities (Hospitals) in specific are
utilising extensive software programs to track their audits, denial management and appeals process. One such audit program is found at the American Hospital Association and known as RACTrack.
• http://www.aha.org/advocacy-‐issues/rac/ractrac.shtml
There is also proprietary software that manages all payer types such as that offered by Craneware Insights. (http://www.cranewareinsight.com/)
The auditor does not need to utilise software programs but can utilise Microsoft programs such as Access and Excel and create template tracking.
Record
Charges Gross
Over
Under
Adjusted Gross Reviewed Settled
123452354 $10,000.00
$0.00
$0.00
$10,000.00
wm
2/29/12
445865
$1,238.00
($12.00)
$0.00
$1,226.00
wm
3/12/12
558366
$8,256.00
($886.00) $124.00
$7,494.00
wm
3/1/12
4498309
$9,250.00
$150
$0.00
$9,400
jj
3/18/12
Databases are essential in the overall management of audits. The auditor must be prepared to discuss and prepare databases as part of the overall deliverable. The database should support the deliverable as either the main exhibit or cross-‐referenced to the executive summary. Databases are essential to all work that the auditor performs.
2C-‐11 PREPARE / SUBMIT COST BENEFIT AND FINANCIAL IMPACT ANALYSIS REPORTS Cost benefit analysis covers many aspects of business decisions. Some of the concepts within the cost-‐ benefit analysis domain are concepts such as return on investment (ROI) and financial justification. While there is no one definition we refer to Wikipedia for a common definition. Wikipedia states: Cost–benefit analysis (CBA), sometimes called benefit–cost analysis (BCA), is a systematic process for calculating and comparing benefits and costs of a project, decision or government policy (hereafter, "project"). CBA has two purposes:
• To determine if it is a sound investment/decision (justification/feasibility),
• To provide a basis for comparing projects. It involves comparing the total expected cost of each option against the total expected benefits, to see whether the benefits outweigh the costs, and by how much.
CBA is related to, but distinct from cost-‐effectiveness analysis. In CBA, benefits and costs are expressed in money terms, and are adjusted for the time value of money, so that all flows of benefits and flows of project costs over time (which tend to occur at different points in time) are expressed on a common basis in terms of their "net present value."
Closely related, but slightly different, formal techniques include cost-‐effectiveness analysis, cost–utility analysis, economic impact analysis, fiscal impact analysis, and Social return on investment (SROI) analysis.
The following is a list of steps that comprise a generic cost-‐benefit analysis. [2] • List alternative projects/programs.
• List stakeholders.
• Select measurement(s) and measure all cost and benefits elements. • Predict outcome of cost and benefits over relevant time period. • Convert all costs and benefits into a common currency.
• Apply discount rate.
• Calculate net present value of project options. • Perform sensitivity analysis.
• Adopt recommended choice.96
As you can see from the above process this fits squarely within the auditor’s domain. Facilities use cost benefit analysis to determine the effectiveness of a particular healthcare programme or a piece of capital equipment under consideration. Healthcare auditors from both the commercial and federal side review records and determine if the cost of providing the care meets their guidelines. Many times a feedback loop will be placed to provide alternate measures such as quality to improve the overall cost-‐ benefit.
The actual audit process will be determined by the measure to be evaluated. These could include a sampling of claims with a particularly high cost to them and determine if the current method of providing care is the most effective. Such an example is the Office of Inspector General reports (OIG) that examine elements stated on their workplan with the overall goal of ensuring integrity of the program as well as looking for ways to be more effective with taxpayer resources.
Some examples of the audits used within the main scheme of healthcare are: http://www.chcs.org/publications3960/publications_show.htm?doc_id=633674