Transcription
Medicare AuditsA Survival Guide forSkilled Nursing FacilitiesMaureen McCarthy, RN, BS, RAC-MT, CQP-MT
Medicare AuditsA Survival Guide forSkilled Nursing FacilitiesMaureen McCarthy, RN, BS, RAC-MT, CQP-MT
Medicare Audits: A Survival Guide for Skilled Nursing Facilities is published by HCPro, a division of BLR.Copyright 2016 HCPro, a division of BLRAll rights reserved. Printed in the United States of America.5 4 3 2 1ISBN: 978-1-55645-895-8No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCProor the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy.HCPro provides information resources for the healthcare industry.HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commissiontrademarks.Maureen McCarthy, RN, BS, RAC-MT, CQP-MT, AuthorAdrienne Trivers, EditorErin Callahan, Vice President, Product Development & Content StrategyElizabeth Petersen, Executive Vice President, HealthcareMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic DesignerPhilip Couch, Cover DesignerAdvice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.Arrangements can be made for quantity discounts. For more information, contact:HCPro100 Winners CircleSuite 300Brentwood, TN 37027Telephone: 800-650-6787Email: customerservice@hcpro.comVisit HCPro online at www.hcpro.com and www.hcmarketplace.com.
ContentsChapter 1: Medicare Oversight of Skilled Nursing Facilities.1Government Oversight.1Fighting Healthcare Fraud.2Government Contractors.6Comprehensive Error Rate Testing Program. 11Medicare Advantage Plans.12Chapter 2: Medical Review Audits. 13The Big Data Effort.13The Medical Review Process .14Types of Medical Reviews .16Prepayment Review.18Postpayment Review.20Claim Review Procedures.28Appeals Backlog.31Summary .32Chapter 3: RAC Audits.35Background.35Recovery Audit Program .36RAC Demonstration Project .37Permanent RAC Program .38Identifying Over- and Underpayment.41Types of Reviews.48Postreview Processes.49Chapter 4: Benefit Integrity Audits.53PSC-to-ZPIC Transition.55Task Order: A/B/DME/HHH.56Task Order: Medi-Medi.56Conducting Program Safeguards.58Purpose and Activities.58 2016 HCProMedicare Audits: A Survival Guide for Skilled Nursing Facilities iii
ContentsHigh-Risk Areas.60Types of Audits.61Audit Process.62Beneficiary Surveys.63Physician Documentation.63Provider Documentation.64Next Steps.67OIG Referral.69Administrative Actions.70Suspension of Payments.70Exclusion From Participation.71OIG Acceptance.73U.S. Attorney’s Office. 74Chapter 5: Comprehensive Error Rate Testing Program.83CERT Contractors.84The Effect of the Long-Term Care Industry.87Chapter 6: Department of Health and Human Services/Office of Inspector General .89Office of Audit Services .89Office of Evaluations and Inspections.90The Office of Investigation (OI).92The Office of Counsel to the Inspector General (OCIG).92Executive Management (EM) .93Chapter 7: Medicare Advantage Plans.95Program Integrity Activities.95Medicare Part C Task Order.97Medicare Advantage Compliance Requirements.98Chapter 8: Case Studies and Scenarios.103Recovery Audit Contractors.103Medical Review.107Benefit Integrity. 111Comprehensive Error Rate Testing Review. 116Office of Audit Services. 119Office of Evaluations and Inspections . 124iv Medicare Audits: A Survival Guide for Skilled Nursing Facilities 2016 HCPro
ContentsChapter 9: Preparing Your Facility for an Audit.135Written Policies and Procedures.137Standards of Conduct.138Risk Areas.138Types of Remuneration.161Stark Law.164Antisupplementation.166Prescription Drug Benefit.167Health Insurance Portability and Accountability Act of 1996 .167Training and Education.168Continuing Education. 174Internal Auditing and Monitoring. 175Optional Steps.179Corrective Action and Enforcement.185Triple-Check System.187Medicare Meetings.189Chapter 10: Post-Audit Processes. 191Review the Findings.191Overpayment.193Limitation on ideration.204Administrative Law Judge Hearing.207Time and Place of Hearing.208Provider Requirements.
Medicare Audits A Survival Guide for Skilled Nursing Facilities Maureen McCarthy, RN, BS, RAC-MT, CQP-MT Reduce the fear of an impending audit and take a proactive approach to preparedness. Medicare Audits: A Survival Guide for Skilled Nursing Facilities provides detailed guidance on the various Medicare audits SNFs face. Author Maureen McCarthy, RN, BS, RAC-MT, CQP-MT, breaks
