1. MEDICAL REVIEW, PROGRAM INTEGRITY
2016 UPDATES
Anne Carey,
Nurse Consultant
August 19, 2016

2. CMS GOALS Promote better care Protect patient safety
CMS dedication:
Promote better care
Protect patient safety
Reduce health care costs
Provide people with access to the right care
when and where they need it 

3. CMS GOALS *Increased focus on transparency and accountability
*Ongoing work with MACs to educate
providers on Medicare policies and
regulations leading to a lower rate of
improper payments, provider burden and
appeals

4. IMPROPER PAYMENT REPORT
How is the Fee for Service Improper Payment Rate Determined?
Comprehensive Error Rate Testing
CERT

5. CERT
CERT is a mandated report performed by an independent contractor CERT evaluates a statistical random sampling of claims nationwide to determine if they were paid properly under Medicare coverage, coding and billing rules

6. Improper Payment Report 2015
 * Fiscal Year (FY) 2015 Medicare FFS program improper payment rate is 12.1 percent, $43.3 billion in improper payments
* FY 2014 improper payment rate-12.7 percent or $45.8 billion in improper payments

7. REMEMBER
Not all improper payments constitute fraud, and high improper payment rates do not necessarily indicate a high rate of fraud
Most Medicare FFS improper payments result from insufficient documentation to determine whether the service or item was medically necessary

8. Significant Results 2015 Improper Error Rate, Inpatient Hospital
CMS and Macs’ educational efforts resulted in a decrease in improper inpatient hospital error rate of 6.2% compared to 9.2% in 2014

9. SIGNIFCANT RESULTS, DME 6 Year Corrective Actions Implemented
DMEPOS Accreditation Program, DME MAC onsite visits to large suppliers, DMEPOS competitive bidding, prior authorization of Power Mobility Devices National DMEPOS improper payment rate significantly decreased from 73.8% ($7.2B) in 2010 to 39.9% ($3.2B) in 2015

10. Significant Results, Home Health
HH services- Main driver of Medicare FFS improper payment rate for past two years FY 2014 (July 1, 2012 – June 30, 2013) 51.4% FY 2015 (July 1, 2013 – June 30, 2014) 58.9% Largely due to insufficient documentation errors when face-to-face encounter narratives did not sufficiently support patient eligibility for the service

11. CMS Change: Face-to-Face Encounter
CMS changed face-to-face encounter requirements for HH episodes beginning on or after January 1, 2015, removing the physician narrative requirement
Change impacts will begin to be reflected in FY 2016 improper payment rate 

12. Pre-Claim Review (PCR) Demo for HH Services
 A 3 year demonstration implemented as a result of findings showing extensive evidence of improper payments, fraud and abuse in the Medicare Home Health program

13. PCR HH Demo Program Goal
Implement PCR as a means of reducing Medicare FFS expenditures for Home Health services by reducing improper payments while maintaining or improving the quality of care experienced by the beneficiary

14. PCR HH Demo Key Points
Request/receive provisional affirmation of coverage after services begin but before the final claim is reviewed
No new documentation is required
PCR helps make sure applicable coverage, payment and coding rules are met before the final claim is submitted

15. PCR HH Demo The demonstration will begin no earlier than:
August 01, 2016 Illinois
October 01, 2016 Florida
December 01, 2016 Texas
January 01, 2017 Michigan and Massachusetts

16. PCR HH DEMO New affirmation required for each 60 day episode of care
If after first 3 months PCR implementation in the demonstration states, a HHA submits a claim for services rendered without a PCR request:
* Claim will undergo prepay medical review
* 25% Payment Reduction if claim approved

17. PCR HH Demo
25% Payment Reduction: Is not appealable and CANNOT be billed to the beneficiary
Standard appeals process applies for claim
If beneficiary accepts services and signs an Advance Beneficiary Notice of Noncoverage, the beneficiary is responsible for payment if Medicare does not pay

18. PCR HH Demo Review Time Requirements
Initial submission PCR request:
MACs are required to make the decision and notify each submitter within 10 business days (excluding Federal holidays) of receipt of the request
Subsequent requests: 20 business days

19. Outreach PCR Demo
CMS, Palmetto, GBA (PCR contractor for ROIV) and the Atlanta Regional Office are participating in Open Door Forums, teleconferences for Congressional offices, Home Health Associations, Hospital and Physician Associations teleconferences. Palmetto is meeting face-to-face with Medical Associations, Medical Societies, Provider Associations

20. PCR HH Demo Outreach
Educational Letters were developed for beneficiaries who have received HH services in the past 6 months, Physicians, HH agencies

21. PROVIDER REVALIDATION
Section 6401A of the ACA established requirements for all enrolled providers and suppliers to resubmit and recertify Medicare enrollment information under new screening criteria

22. Provider Revalidation
CMS completed Cycle 1 March, 2015
Cycle 2 began March, 2016
Due dates:
Failure to submit documents timely results in deactivation

23. Takeaway’s
Services provided during the ‘gap’, deactivation, reactivation period for providers are NOT the responsibility of the beneficiary

24. 7/20/16 CMS PE Moratoria Announcement
Six month extension and expansion statewide of temporary PE moratoria on new Medicare Part B non‑emergency ground ambulance suppliers:
New Jersey, Pennsylvania, Texas and, new
Home Health agencies in Florida, Texas,
Illinois and Michigan
* The statewide expansion also applies to
Medicaid and CHIP 

25. Provider Enrollment Waiver Demonstration, PEWD
Allows for PE exceptions in moratoria areas if access to care issues are identified
Allows for development/improvement for methods of investigating and prosecuting fraud in Medicare, Medicaid and CHIP

26. CMS TRANSPARENCY OPEN PAYMENTS
The Open Payments program (“Sunshine Act”) requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals be published for public information:

27. CMS Transparency-Open Payments 2015
Health care industry manufacturers reported $7.52 billion in payments, ownership and investment interests to physicians and teaching hospitals
Comprised of million total records attributable to 618,931 physicians and 1,116 teaching hospitals 
Three major reporting categories:
* 2.60 billion in general (non-research related) payments
* 3.89 billion in research payments
* 1.03 billion of ownership or investment interests held by
physicians or their immediate family members

28. CMS Transparency-Open Payments
Over the course of the Open Payments program since 2014, CMS published million records, accounting for $16.77 billion in payments and ownership and investment interests.

29. 7/20/16 Highlights Medicare Medicaid Program Integrity Report to Congress
$42 Billion Saved in Medicare and Medicaid Primarily Through Prevention over the two-year period covered by the report Average savings of $12.40 for each dollar spent on Medicare Program Integrity alone.

30. 7/20/16 Highlights Medicare Medicaid Program Integrity Report to Congress
Moving away from ‘pay and chase’ results:
FY 2013, savings from prevention activities represented about 68 percent of total savings
FY 2014, portion of savings from preventing potentially fraudulent and improper payments rose to nearly 74 percent
CMS will release FY 2015 numbers later this year

31. Questions ???? Anne Carey Louisa.carey@cms.hhs.gov Desmica Head