Risk Management Proposal for the UAE Hospitals

Risk Management Proposal for the UAE Hospitals

BILLING COMPLIANCE COMMITTEE MEETING September 15, 2011 1 MEETING AGENDA 1. Introductions of New Compliance Staff 2. Active Medicare Local Coverage Determinations (LCD) 3. Upcoming Medicare Training and Education Sessions 4. Medicare Advanced Beneficiary Notice (ABN) Form Change 5. Provider Enrollment Revalidation Requirements for Providers Participating

in Medicare, Medicaid and the Childrens Health Insurance Program (CHIP) March 1, 2020 2 AGENDA MEETING (contd) 6. Medicare and Medicaid Audit Updates 7. FY 2012 Compliance Audit Work Plan 8. Discussion of Each Clinics Responsibility to Maintain Internal Billing Guidelines and Conduct Self Audits 9. Compliance News and Updates March 1, 2020

3 Medicare Active LCDs Source: https://www.highmarkmedicareservices.com/policy/ Active LCDS Acute Care: Inpatient, Observation and Treatment Room Services B-Type Natriuretic Peptide (BNP) Assays Blepharoplasty/Blepharoptosis Blood Glucose Monitoring in a Skilled Nursing Facility C-Reactive Protein Testing Cardiac Rehabilitation Program Services Erythropoiesis Stimulating Agents (ESAs) March 1, 2020 4

Medicare Active LCDs Contd Cardiac Rhythm Device Evaluation Cardiovascular Nuclear Medicine

Cardiovascular Stress Testing Cataract Surgery Complex Cataract Extraction Chiropractic Services Co-Management of Surgical Procedures Computed Tomographic Angiography of the Chest Continuous Glucose Monitoring Coverage of services and Procedures in Nursing Facilities End-Diastolic Pneumatic Compression Therapy Evaluation and management Services Provided in a Nursing Facility March 1, 2020 5 Medicare Active LCDs Contd

Cytogenetic Analysis Debridement of Mycotic Nails Diagnostic Laryngoscopy

Dynamic Electrocardiography Electrocardiography Electromyography (EMG) and Nerve Conduction Studies Extended Ophthalmoscopy Fluorescein and Indocyanine Green Angiiography Fundus Photography Human Skin Equivalents Hyperbaric Oxygen Therapy Infrared Photocoagulation (IRC) of Hemorrhoids Intraoperative Neurophysiological Testing March 1, 2020 6 Medicare Active LCDs Contd Injectable Collagenase Clostridium Histolyticum for Dupuytrens

Contracture Isolated Ultrafiltration for Managemnet of Fluid Overload in Cardiac Disease Loss of heterozygosity Based Topographic Genotyping with PathFinder TG Luteinizing Hormone-Releasing Hormone (LHRH) Analogs Magnetic Pelvic Floor Stimulation (MPFS) Magnetic Resonance Angiography (MRA) Magnetic Resonance Imaging (MRI) of the Breast Mohs Micrographic Surgery Monitored Anesthesia Care Non Covered Services March 1, 2020 7 Medicare Active LCDs Contd

Non-Invasive Cerebrovascular Arterial Studies Non-Invasive Peripheral Venous Syudies Non-Vascular Extremity Ultrasound Ophthalmic A and B Scans

Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation OVA 1 Assay Paraathormone (Parathyroid Hormone) Physical Medicine & Rehabilitation Services; PT, OT Proton Beam Therapy Psychiatric Therapeutic Procedures Pulmonary Rehabilitation Services Program Wound Care March 1, 2020 8 Medicare Active LCDs Contd

Qualitative Drug Testing Radiation Therapy Services Radiofrequency Treatment for Urinary Incontinence Radiologic Examination of the Chest RAST Type Tests

Real-Time Outpatient Cardiac Telemetry Removal of Benign or Premalignant Skin Lesions Removal of Impacted Cerumen Routine Foot Care Scanning Computerized Ophthalmic Imaging Visual Fields Vitamin B12 Assays Vitamin D Assay Testing March 1, 2020 9 Medicare Active LCDs Contd Serotypes A and B Botulinum Sleep Disorders Testing Speech Language Pathology (SLP) Services;Communication

Disorders SLP Services: Dysphagia;Includes VitalStim Therapy Stereotactic Body RadiationTherapy (SBRT) Surgical Treatment of Nails Thermotherapies (MISTS) for Benign Prostatic Hyperplasia Transesophageal Echocardiography (TEE) Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections Treatment of Varicose Veins of the Lower Extremeties Trigger Point Injections March 1, 2020 10 Upcoming Medicare Education and Training Sessions Observation Services

Workshop Rehabilitation Billing Blood Glucose SNF Rehabilitation Resource Utilization Group (RUGs) Hyperbaric Oxygen Billing Laboratory and Radiology Services Inpatient Versus Observation for Acute Care Facilities Chemotherapy , Injection and Infusion Services Sleep Studies

Wound Care Modifiers for Part A providers Medicare Advanced Beneficiary Notice (ABN) Form Change Revised ABN form CMS R-131 has a mandatory use date of 11/1/2011. We must get rid of all old versions of the ABN and discontinue using them. All required sections of the ABN must be completed for the form to be valid. (Medicare Claims Processing Manual, Chapter 30, section 50.6.3) The ABN must list the specific items or services believed to be non-covered. The estimated cost provided on the ABN must be within $100 or 25 percent of the actual costs.

March 1, 2020 12 Required Medicare and Medicaid Provider Enrollment Revalidation On 8/10/11 CMS published a MLN Matters article SE1126 to inform providers of new enrollment revalidation and screening processes. Rules apply to any provider who enrolled in Medicare, Medicaid, and the Childrens Health Insurance Program (CHIP) on or before 3/25/11. March 1, 2020 13

Required Medicare and Medicaid Provider Enrollment Revalidation CMS will issue letters between now and March 2013 to all providers that need to revalidate enrollment. Do not revalidate until requested by CMS Assistance in completing the application process is available. Please contact Stephanie Mackowiak at (410)955-8577 No Medicare or Medicaid enrollment or revalidation forms should be submitted without review by Compliance!! March 1, 2020 14

Medicare Recovery Audit Contractor (RAC) Updates **Approved for Maryland** RAC Medical Necessity Reviews 1. Cardiac Catherization for Ischemic Heart Disease 2. Chest Pain 3. Syncope 4. Transient Ischemia 5. Vertigo and Other Labyrinth Disorders 6. Chronic Obstructive Pulmonary Disease March 1, 2020 15 Medicaid RACs Currently on hold until States can better

operationalize. No firm date to start in sight. Will look for overpayments and underpayments and supplement the work of current Medicaid audit programs (e.g., MICs, MCFCU, etc.) Recommend close tracking of cases so no duplication occurs. Medicaid does not have the ability to track like Medicare. Insights from Marylands (DHMH) Office of the Inspector General March 1, 2020 16 FY 2012 Compliance Audit Work Plan Health System Wide Compliance

Initiatives - Practitioner Licensure and Credentialing Verifications - Education Initiatives to include: 1.Observation Services 2. Medicare One-Day Stays 3. ED Visit Documentation and Billing Rules March 1, 2020 17 FY12 Compliance Audit Work Plan Contd JHBMC Scheduled Audits 1.Pulmonary Rehabilitation Services 2.Community Psychiatry IOP Program 3.Cardiology Diuresis Clinic

4.PET Scan Services 5.Wound Care 6.ATS Program March 1, 2020 18 FY12 Compliance Audit Work Plan Contd JHH Scheduled Audits 1.Interventional Radiology Services 2.Wilmer Eye Low Vision Clinic 3.Outpatient Psychiatric Services 4.Weinberg Outpatient Pharmacy 5.Infusion Services 6.Radiation Oncology March 1, 2020

19 FY12 Compliance Audit Work Plan Contd HCGH Scheduled Audits 1.Blood Transfusion Services 2.ED Visit Level Billing 3.Pain Management Services 4.Medical Nutrition Services 5.Wound Care Services March 1, 2020 20 FY12 Compliance Audit Work Plan Contd

Suburban Hospital Scheduled Audits 1.Cardiac Rehabilitation Follow Up 2.Ultrasound Services 3.Partial Hospitalization Services 4.Ambulatory Surgery Center 5.Eye Surgeries 6.Outpatient Breast Reconstruction Surgeries March 1, 2020 21 FY12 Compliance Audit Work Plan Contd Sibley Scheduled Audits 1.Outpatient Infusion Services 2.Inpatient Rehabilitation Services and 3

Day SNF Qualifying Stay 3.ED Visit Billing March 1, 2020 22 FY12 Compliance Audit Work Plan JHHCG Scheduled Audits 1.Home Health Face to Face Encounter Requirement 2.Medicaid Home Health Agency Claims Review to Include Adult and Pediatric Lines of Business 3.DME & IV Credit Balance Review March 1, 2020

23 FY12 Compliance Audit Work Plan Contd JHHCG Scheduled Audits 4. Review of Compliance with DMEPOS Supplier Standard #28 5. Pharmaquip Compliance with Medicare Coverage Requirements for CPAP Devices March 1, 2020 24 FY12 Compliance Audit Work Plan Contd

Other JHHS Scheduled Audits 1.Potomac Home Health Agency 2.Cardiovascular Specialists of Central Maryland (via the CPA) 3.HCGH OB/GYN Associates Series March 1, 2020 25 Discussion of Internal Billing Guidelines and Self Audit Processes Each department should have a policy or procedure that describes how you document and bill services Self Audits should be performed

monthly to insure billing policies and procedures are being followed.(JHHS Finance Policy Fin 125) March 1, 2020 26 Compliance News & Updates Medicare Focused Review activities New OIG reviews show OIG targeting multiple risk areas at the same time inclusive of a review of internal controls and compliance program effectiveness review (See OIG report number A-01-10-00527, Fletcher Allen Health Care) Updates on Medicare Appeals and ALJ Hearings March 1, 2020

27 Whats on the Horizon New ICD 9 CM procedure codes go into effect October 1, 2011. The CMS website link is : https://ww.cms.gov/ICD9ProviderDiagnosticCodes/04-addendum.asp Clarifications to Condition code 44 policy issued 9/2/11 and effective 10/1/11. (See Medicare Transmittal 2296 and Medicare Claims Processing Manual, Chapter 1, section 50.3.1 and 50.3.2 March 1, 2020 28

QUESTIONS?? **The BCC presentation and all handouts are available on the Compliance Website: www.insidehopkinsmedicine.org/JHHSCompliance THANKS FOR YOUR PARTICIPATION! March 1, 2020 29

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