1. Auditors: Who’s Looking, What They’re Looking For & Why
Presented by:
G. Christopher Kelly

2. Who’s Looking? OIG- Work Plan, Whistleblowers, etc
MACs (pre-pay and prior authorization)
Post Pay:
ZPICs
RACs
SMRC- Supplemental Medical Review Contractor:
Strategic Health Solutions
National contract- national claims data
ZPIC power! (can extrapolate damages)
Already looking at ambulance

3. Risks and Rewards: Who and Why: Preparation:
MACs (Contract)
ZPICs (Budget)
RACs (Bounty)
HHS/OIG- (Job)
MICs (Fed Match)
Qui Tam- (Reward)
Preparation:
Can’t stay under the radar
Dialysis
ALS
SCT
Peer Comparison Reports
Intent is every 5 years
09/29/11

4. New Tactics OIG- Civil Investigative Demands ZPICs-
Looking for date ranges
Taking one DOS but reviewing against others
Providing “Education”
Extrapolation only when-
“High Rate of Error” or
“Prior Education failed to correct”

5. Pre-Pay Review MAC actions TX (Novitas)‏ FL (1st Coast)‏
GA/AL/TN (Cahaba)‏
Authority to Review
Completely Discretionary
Quarterly error rate
Appeal? Ha!
Strategy to Defeat
Dot the “i's”
ALS explanation
BLS justification

6. OIG Audits of the Ambulance Industry
Medical Necessity
25% of all transports did not meet program requirements
$402 Million in overpayments
Non-emergent: 27% of dialysis patients and 20% of all other transports
Emergent: 7% of transports
Overpayments are the new Balanced Budget

7. Most Common Coding Issues
Level of Service (ALS v. BLS)‏
Immediate Response (was it an emergency)‏
Medical Necessity of the trip
Medical Necessity of the transfer
Mileage

8. The “Errors”....

9. How can you show “contraindicated”?
Denial #1
How can you show “contraindicated”?
Objective conditions to support Subjective conclusions
“Functional Assessments”
Document details:
O2 sat
Pillows and placement
Source & Scale of Pain
BLS skills required
Explain Why!
Documentation does not support medical necessity/trans port by other means possible.

10. No PCS on file. Denial # 2 Must keep track of these Good for 60 days
BUT attach 1 for each claim
No PCS on file.

11. Auditors LOVE calendars
Denial # 3
Auditors LOVE calendars
Must be legible
Must have the YEAR
Should be done at the same time as the signature (typed dates are often questioned)
PCS has invalid date.

12. PCS has invalid signature.
Denial # 4
Auditors watch for:
Legibility
Printed names
Credentials
Exclusions
Draft Templates??
PCS has invalid signature.

13. Patient signature or alternate not captured.
Denial # 5
Assignment of Benefits rule must be followed
Patient should sign if possible
If the patient can not sign, 5 alternates:
1. Patient’s legal guardian
2. Patient’s healthcare power of attorney
3. Person who receives gov benefits on patient’s behalf
4. Person who arranges patient’s medical appointments
5. Representative of provider who cares for patient
Document which one it is!
If no alternate is available:
Crew signs explaining WHY patient didn’t sign
Crew must get receiving facility to sign
Patient signature or alternate not captured.

14. ALS not justified (downcode)‏
Denial # 6
Must document what ALS procedure was done
Must document why it was necessary
ALS crew must be present
ALS Assessment Rule
ALS not justified (downcode)‏

15. Emergency not justified (downcode)‏
Denial # 7
Was there an immediate response
Did call justify an immediate response
Were there dispatch protocols
H-H transfers
Emergency not justified (downcode)‏

16. Covered Destination Modifier?
Denial # 8
Covered Destination Modifier?
Correct Destination Modifier?
Does the modifier match the narrative?
Transport to destination not covered by Medicare.

17. Did you bypass another facility?
Could another facility have treated:
that patient ?
on that day?
Document out-of-the ordinary at the time of transport!
Locality Rule
Denial # 9
Transportation not to nearest appropriate facility (downcode mileage)‏

18. Why was second facility the closest?
Denial # 10
H-H transfers-
What was needed?
What was not available?
Why was second facility the closest?
Rarely can you pass another facility- but it can happen and be paid
Was there an immediate need for the transfer?
Transport to second facility not appropriate (no higher level of care indicated or patient preference indicated)‏

19. Patient Documentation: What the QIC is Looking For
Concise explanation of symptoms from patient and other observers.
Details of the patient’s physical assessments that demonstrates the need for an ambulance.
Objective description of the patient’s physical condition, in detail, that demonstrates the patient meets Medicare limitation of coverage for ambulance services.
Description of the traumatic event when trauma in the basis for suspected injuries.
Detailed description of existing safety issues.
Detailed description of special precautions taken, and an explanation of the need for the precautions.
Description of specific monitoring and treatments required, ordered and performed, or administered such as O2 and/or cardiac monitoring. For example, if O2 is administered, the pretreatment capillary blood O2 and clinical respiratory description should be recorded and be consistent to meet O2 need.
Statements, such as the following, without supporting information are not sufficient to justify Medicare payment for ambulance services:
Headache
Hip Pain
Back Pain
Leg Pain
Weakness
Bed-confined

20. Why it Matters: Extrapolation
Sample of 50 dates of service during 2 years
Finding that 20 did not justify payment (40%)‏
Actual overpayment of $5,000
Actual transports during 2 years = 4,800
Actual amount paid for 2 years = $1,200,000
40% of $1,200,000 = $480,000
So a $5,000 actual overpayment turns into a $480,000 extrapolated overpayment.

21. Some Real Examples:

22. Appeals Process Audit Request/Decision (6 months+)
Re-determination (2 months)
Qualified Independent Contractor (6 months)
Administrative Law Judge (2 years)
Medicare Appeals Council (6-9 months)
U.S. District Court (6 months)
4+ years from time of initial audit
*Repayments and Offsets Start at end of QIC

23. Redetermination Favorable
ALJ
Date
State
Total # of Claims
Redetermination Favorable
Redetermination Lose
% Favorable
QIC Favorable
QIC Unfavorable
ALJ Favorable
ALJ Unfavorable
Total % Favorable
July, 2014 TX
104 4
100 4% 96
92%
100%
Aug, 2014
120 0% 74 46
62% OH 67 17 50
25% 2 15 3%
28%
Feb, 2015 40 10 30 5 25
13%
38%
Apr, 2015 NC 39 3 34 8%
July, 2015 GA 27 8 19
30% 11
41% 36
10% 5%
85%
Aug, 2016
210 79
131
129
61%
99%
Apr, 2016 SC
12%
24% 6
29%
65%
132 12 9% FL 64 58 7 51
118 45 1 44 2% 43
350
340
349
144
143 1%
711
996

26. Questions, comments, concerns: