Plan of Care Medical Review Process Appeals Process Presented by: Representatives of Palmetto GBA at the 2008 TX&NM Hospice Organization’s Annual Conference.

Plan of Care Medical Review ProcessAppeals Process

Presented by: Representatives of Palmetto GBA at the 2008

TX&NM Hospice Organization’s Annual Conference

Pre-Session Questions and Answers3 minutes

Objectives

Understand the Plan of Care and Role of the Interdisciplinary Group (IDG)

Documentation which Supports the Terminal Diagnosis

Identify Steps in the Medical Review Process

Respond Appropriately to Requests for Medical Records

Understand the Appeals Process

Plan of Care

A written plan of care (POC) must be established and maintained for each individual admitted to the hospice program, and the care provided to an individual must be in accordance with the plan.

42 CFR 418.58 The Medicare Conditions of Participation for Hospice Care

Plan of Care

No standard format

Initial Plan must be established before services are rendered

The plan of care should be kept on file at the hospice agency and if the beneficiary has an in-patient episode, shared with the contracted facility

Plan of CareThe member of the Interdisciplinary Group (IDG)

who assesses the patient must consult with at least one other member of the IDG before establishing the Plan.

The attending physician and medical director must review the POC within two calendar days of its establishment.

The POC must detail the scope and frequency of services to meet the patient’s and family’s needs-must be beneficiary specific.

Plan of Care

“Once the beneficiary elects hospice care, the hospice is responsible for furnishing directly, or arranging for, all supplies and services that relate to the beneficiary's terminal condition, except the services of an attending physician.”

Publication of the Medicare Advisory Bulletin on Hospice Benefits. Federal Register Vol.60, No 212. 1995

Plan of Care

Should only include services which are reasonable and necessary for the palliation and management of the patient’s terminal illness and related condition

Should be individualized

Should be reviewed at least each benefit period and any time the patient’s condition or level of care changes

Plan of CareDiscuss any changes in POC

Anticipate future issues/problems

Confirm ongoing hospice appropriateness

Measurable outcomes

Interventions should relate to problems identified during assessment

Plan of Care

Manage symptoms

Prepare family and patient for death

Support through the process

Help patient and family make transition from curative to palliative treatment mode

Hospice Services Medicare-certified hospices may provide

Nursing care

Social Services

Home care/home maker services

Physical therapy

Occupational therapy

Medical equipment

Other services may vary

Physician Services

Spiritual counseling

Dietary counseling

Speech/language pathology services

Short term in-patient care

Supplies

Key to Success

“The key to success at hospice is the team concept. The team concept provides much greater support than any one discipline could ever provide. It takes the physician and all the hospice staff to deliver quality of life at this time.”

Fred Isaacs, M.D. Internal Medicine

Members of the IDG

Doctor of Medicine or Osteopathy

Registered Nurse

Social Worker

Pastoral or other counselor

42 CFR 418.68 The Medicare Conditions of Participation for Hospice Care

Role of IDG1. Participation in the establishment of the plan of care

2. Provision or supervision of hospice care and services

3. Periodic review and updating of the plan of care for each individual receiving hospice care

4. Establishment of policies governing the day to day provision of hospice care and services

42 CFR 418.68 The Medicare Conditions of Participation for Hospice Care

Medical Director

The Medical Director is a Doctor of Medicine or Osteopathy who assumes overall responsibility for the medical component of the hospice’s patient care program.

42 CFR 418.54 The Medicare Conditions of Participation for Hospice Care

Medical Director Responsibilities

Consults with the Attending Physician

Reviews patient eligibility for hospice services

Acts as a medical resource for the interdisciplinary team

Physician Involvement

“Through hospice care, physicians can become a part of a team that ensures effective management of their patient’s pain and other physical symptoms as well as their broader psychological and spiritual needs. No patient need be helpless and alone when facing a terminal illness.”

•Hospice Care: A Physician's Guide.Michigan Hospice and Palliative care Organization. 2006

Nursing Services

The hospice must provide nursing care and services by or under the supervision of a registered nurse.

42 CFR 418.82 The Medicare Conditions of Participation for Hospice Care

Nursing Services1. Nursing services must be directed and

staffed to assure that the nursing needs of patients are met.

2. Patient care responsibilities of nursing personnel must be specified.

3. Services must be provided in accordance with recognized standards of practice.

42 CFR 418.82 The Medicare Conditions of Participation for Hospice Care

Nursing Services

“Hospice nurses do anything and everything it takes to keep our patients and families—in the time that they have—comfortable. Pain management is a priority. There is so much we do, the little things, that we do not even realize we do.”

5 minutes with Lynn Taylor on Hospice Nursing:Caroline Sniffen Smith, MSN, FNP, RN Nurseweek: March 4, 2002

Medical Social Services

Medical social services must be provided by a qualified social worker, under the direction of a physician.

42 CFR 418.84 The Medicare Conditions of Participation for Hospice Care

Medical Social Services Assessment of the social and emotional factors related to

the beneficiary's need for care, response to treatment and adjustment to care

Assessment of the relationship of the patient’s medical and nursing requirements to the patient’s home situation, financial resources and availability of community resources

Appropriate action to obtain available community resources to assist in resolving the patient’s problem

CMS Manual System, Pub 100-02, Medicare Benefit Policy, Chapter 9, Section 40.1.2

Social Work Assessment

Areas for consideration in the comprehensive assessment include:

• Relevant past and current health situation (including the impact of problems such as pain, depression, anxiety, delirium, decreased mobility)

• Family structure and roles

• Patterns/style of communication and decision making in the family

Social Work Assessment Stage in the life cycle, relevant developmental issues

Spirituality/faith

Cultural values and beliefs

Client's/family's language preference and available translation services

Client's/family's goals in palliative and end of life treatment

Social Work Assessment Social supports, including support systems, informal and

formal caregivers involved, resources available, and barriers to access

Past experience with illness, disability, death, and loss

Mental health functioning including history, coping style, crisis management skills

NASW Standards for Social Work Practice in Palliative and End of Life Care ©2007 National Association of Social Workers.

Social Work Services

“ I find great fulfillment in helping a loved one find ways to manage the pain of their loss and often to find meaning in that loss. I also enjoy working with patients and families to have a sense of closure and preparedness for the patient's death.  People deserve privacy, respect and time alone with the people they love in an environment in which they are comfortable…”

Ethel Forward, MSW,Social Work, Spiritual Care & Bereavement Coordinator, Hospice of Chenango County

Counseling Services Must be available to both the individual and the family

Bereavement counseling after the patient’s death

Dietary

Spiritual

Other counseling services

42 CFR 418.88 The Medicare Conditions of Participation for Hospice Care

Counseling ServicesInterventions commonly provided in palliative

and end of life care include: • Individual counseling and psychotherapy (including

addressing the cognitive behavioral interventions)

• Family counseling

• Family-team conferencing

• Crisis counseling

• Information and education

Counseling Services Multidimensional interventions regarding symptom

management

Support groups, bereavement groups

Case management and discharge planning

Decision making and the implications of various

treatment alternatives

Counseling Services

Resource counseling (including caregiving resources; alternate level of care options such as long term care or hospice care; financial and legal needs; advance directives; and permanency planning for dependants)

Client advocacy/navigation of systems.

Pastoral Counseling

“Pastoral Counseling is a unique and challenging career. Individuals must develop and maintain skills in two distinct areas – counseling and ministry. It is a major challenge to maintain professional competence in these two unique fields. This dedication to service speaks highly of those who choose to walk this path…..”

The National Board for Certified Pastoral Counselors

Home Health Aide

Home health aide and home maker services must be made available and adequate in frequency to meet the needs of the patients.

42 CFR 418.94 The Medicare Conditions of Participation for Hospice Care

Home Health Aide

An R.N. must visit the home site at least every two weeks when aide services are being provided

The visit must include an assessment of aide services

Written instructions for patient care are prepared by a registered nurse

I’m Only a CNA….

“I am the one offering hugs and smiles in a dark and lonely world, where many times, the staff becomes the only family a patient has. I become their source of love, acceptance and friendship. I am the one who tries to quell loneliness and depression in the people I care for. I am the one who makes them know that someone still cares about them.

I’m Only a CNA….

I am the one who listens when no one else listens. I listen as my patients repeat stories from their past over and over again, and offer my words of amazement or encouragement over their accomplishments and memories. I am the one who validates them as a person, who ensures they know they still have great worth as a human being, even though they may be physically or mentally ill and their lives have changed, I always try to offer hope where it is needed.

I’m Only a CNA….I am the one who comforts and holds the hand of my patient as they slowly slip away. I am the one who has been there by their side, when no one else was, so they were not alone when they left this world. I am the one who offered a prayer and words of peace, while gently stroking their head and reassuring them it was "ok to let go“.

“I’m only a CNA…”Copyright 2001, Rachel Giarrizzo, www.NursingAssistantCentral.com

Documentation of Care

Assess and evaluate the whole person and the entirety of the illness:

• Co-morbid conditions

• Secondary conditions

Disease Progression

Establish a baseline:• Admission assessment

• Existing information from medical records

Disease Progression

Decrease in Functional Status:• FAST

• Karnofsky

• PPS

The Functional Assessment Staging Scale (FAST)

Seven stages of Alzheimer’s Disease:1. Normal adult

2. Normal older adult

3. Early Alzheimer's disease

4. Mild Alzheimer's disease

5. Moderate Alzheimer's disease

6. Moderately severe Alzheimer's disease

7. Severe Alzheimer's disease

Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653- 59

KARNOFSKY PERFORMANCE STATUS SCALE

100 – Normal, no complaints, no evidence of disease 90 – Able to carry on normal activity, minor signs or symptoms of disease 80 – Normal activity with effort, some signs or symptoms of disease 70 – Cares for self, unable to carry on normal activity or to do work 60 – Requires occasional assistance from others but able to care for most

needs 50 – Requires considerable assistance from others; frequent medical care 40 – Disabled, requires special care and assistance 30 – Severely disabled, hospitalization indicated; death not imminent 20 – Very sick, hospitalization necessary, active supportive treatment

necessary 10 – Moribund

Journal of Clinical Oncology, Vol 2, 187-193, Copyright © 1984 by American Society of Clinical Oncology

PALLIATIVE PERFORMANCE SCALE (PPS)

% Ambulation Activity and Evidence of Disease

Self-Care Intake Conscious Level

100 Full Normal ActivityNo Evidence of Disease

Full Normal Full

90 Full Normal ActivitySome Evidence of Disease

Full Normal Full

80 Full Normal Activity with EffortSome Evidence of Disease

Full Normalor Reduced

Full

70 Reduced Unable Normal Job / WorkSome Evidence of Disease

Full Normalor Reduced

Full

60 Reduced Unable Hobby / House WorkSignificant Disease

Occasional Assistance Necessary

Normalor Reduced

Full orConfusion

50 Mainly Sit/Lie

Unable to Do Any WorkExtensive Disease

Considerable AssistanceNecessary

Normalor Reduced

Full orConfusion

40 Mainly in Bed

As Above Mainly Assistance Normaor Reduced

Full or Drowsyor Confusion

30 Totally Bed Bound

As Above Total Care Reduced Full or Drowsyor Confusion

20 As Above As Above Total Care Minimal Sips

Full or Drowsyor Confusion

10 As Above As Above Total Care Mouth Care Only

Drowsy orComa

0 Death - - - -

Anderson, Fern et al. (1996) Palliative Performance Scale (PPS) a new tool. Journal of Palliative Care 12(1), 5-11

Disease Progression

Dependence in ADLs:• Ambulation• Continence• Transferring• Dressing• Feeding• Bathing

Disease Progression

Description of symptoms:• Not due to reversible causes

• Not responsive to treatment

Symptom Management

Document the management/palliation of symptoms:

• Pain• Nausea and vomiting• Complications of being bedridden

What is Pain?

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

International Association for the Study of Pain

Documentation of Pain

Location: where is the pain?• Localized• Diffuse• Referred

Documentation of Pain

Character of pain?• Dull • Sharp• Throbbing• Shooting• Burning

Documentation of PainOnset

Frequency

Duration

Intensity

Exacerbation

Alleviation

Documentation of Pain

Does pain lead to:• Nausea• Fatigue• Weakness• Dyspnea• Limitations in mobility

Pain Assessment Tools

“Pain is a subjective experience and no objective tests exist to measure it”

American Pain Society. (2003). Principles of analgesic use in the treatment of acute pain and cancer pain.

Initial Pain Assessment

McCaffery and Beebe (1989). Pain: Clinical manual for nursing practice. St. Louis: CV Mosby Co..

Pain Drawing

Numerical Scale

Memorial Pain Assessment Card

CNVI

Checklist of Non-Verbal Indicators

Wong-Baker FACES Scale

PAINAD Scale

Warden, Hurley, Volicer, JAMDA 2003; 4(1): 9-15, Developed by the Geriatric Research Education Clinical Center (GRECC), VAMC, Bedford, MA

Nausea and Vomiting

Document complications from nausea vomiting:

• Dehydration• Aspiration• Desire not to eat• Inability to lay flat

Bed-Ridden

Document complications from being bed bound:

• Skin breakdown• Contractures• UTI• Respiratory infections• Muscle weakness

The Progressive Corrective Action (PCA)

Progressive Corrective Action (PCA) The method used to identify and implement the

processes performed under medical review

Requirement per Section 1816 of the Social Security Act

Includes data analysis, medical review of claims, and provider education

CMS Manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 11.1

Goals of PCA

Maximize program protection against inappropriate payments

Decrease receipt of claims for non-covered or unnecessary services

Educate providers on appropriate practices

Assist in improving quality of care for beneficiaries

Avoid inconvenience to providers who adhere to the program requirements

PCA

Data analysis• First step

• Identification of aberrancies

• Part of general surveillance

• Conducted in response to information about specific problems

PCA

Service-specific probe• Based on a specific service

• Random sampling among all providers billing the service in question

• 100 total claims selected for review

• An article is posted on the Palmetto GBA web site to

– Notify the provider community of the probe, and– Notify the provider community of the results

PCA

Provider-specific probe• Notified via individual letter

• Sampling of 20-40 claims

• A predetermined percentage of claims billed will be selected for medical review every time the provider bills

• Provider notified of results via individual letter after claims are reviewed and processed

PCA

Pre-pay review: • Selects a percentage of claims billed after services are

rendered

• An edit is established through the claims processing system (FISS) that selects the claims for review

• Additional Development Requests (ADRs) are generated and medical records are reviewed before claim processing is completed

PCA

Post-pay review : • Selects claims that have previously paid through the

processing system

• Providers receive a letter identifying the claims for which medical records must be submitted

• When a post-pay review determination results in a denial of services, the claims will be adjusted to recoup the overpayment

• Written notification of the results is sent to the provider upon completion of the review

The Results of the Medical Review

The determination of whether the medical review is discontinued or resumed is based on data analysis of the reviewed and processed claims

The result of the data analysis is expressed as a percentage and is identified as a Charge Denial Rate (CDR)

Charge Denial Rate

Total $ charges denied

on the number of claims reviewed

Divided by

Total $ charges

on the number of claims reviewed and processed

Multiplied by 100 = CDR

The Medical Review ProcessIn General:

• Discontinued:–Low CDR 0%-9% –Low CDR 10%-15% - education provided,

possible re-probe in six months• Continued:

–Moderate CDR 16%-50% –Moderate CDR 16%-50% - after two quarters, a

written Corrective Action Plan (CAP) is requested• Continued and CAP requested:

–High CDR 51%-100%

The Medical Review Process

After one year of medical review with limited or no improvement, the provider may be referred for:

• Program exclusion, • Suspension of payment,

• Civil monetary penalty, • Benefits integrity unit (fraud referral),

• Comprehensive (postpay) medical review and/or

• Withholding of payment

The Medical Review Process

Provider Education and Training

1 -Claim selected based on data analysis

2 – Records requested

3 – Documentation received

4 – Determination made5 – Appeals options

6 – Statistics Reviewed

7 – Edit Decision

8 - Medical Review continues or ends

References

CMS Manual System Pub. 100-08, Medicare Program Integrity

Manual, Chapter 3, Sections 3.2, 3.4, 3.5 and 3.11

Palmetto GBA Web site April 2007 Medicare Advisory: “Medical

Review Progressive Corrective Action (PCA) Process”

Additional Development Requests (ADR)What is an ADR? Request for copies of medical records on a specific

beneficiary for specific dates of service

The ADR arrives via the mail in a bright yellow envelope with a red stamp “ADR Requests Time Sensitive”

How long do I have to respond? The provider has 30 days from the date on the ADR to

respond to Palmetto GBA with copies of the requested medical records

ADR

How do I know a claim has been selected for review?

• Watch for the yellow envelope containing the ADR, OR

• Monitor your claims through the Direct Data Entry (DDE) system

• To determine the 30 day time period, the date on the ADR letter equals the date the claim went to S/L SB6001 in DDE system

ADRHow do I monitor my claims on DDE?Direct Data Entry (DDE)

To see the total number of claims in ADR status: At main menu select 01 for inquiry Select 56 for Claims Count Summary Tab to the S/LOC field and enter SB6001 Status/location SB6001 will show the total

number of claims in ADR status

ADRTo view individual claims in ADR status:

• At Main Menu of HIQA select 01 for inquiry

• Select 12 for claims sub-menu

• Tab to the S/LOC field and enter SB6001

• To view/print ADR letter, select the claim and press enter

• The ADR letter follows claim page 6

• Do not use the F9 key while in these claims; it causes a new ADR to generate

ADRHow do I know what to send?Inside the yellow envelope are brightly colored

inserts with instructions on how to respond to the ADR and what to send

Included in your handout are copies of these inserts

Visit www.PalmettoGBA.com for an article

entitled: “How to Respond to an Additional Development Request (ADR) from Palmetto GBA

ADR Helpful Hints

May send more than one ADR response in an envelope

Separate each response

Each response should have a copy of the ADR letter or DDE screen print ADR attached to the front

Make sure information submitted is for the appropriate beneficiary and dates of service

ADR Hints

One staple to attach all documents to each individual ADR

Do NOT use paper clips to secure pages of document

Copies should be legible

Copy both sides of 2-sided copies

Number all pages

Use a checklist!!!!!

ADRWhere do I send it?

• The ADR contains the address to which you are to respond

• Please note that the “Mail Code” on the ADR will not always be the same–For probe reviews it will be: AG-232–For postpay reviews it will be AG-220–All other claims will go to AG-230

ADR

For regular postal delivery mail, including priority or certified:

Palmetto GBA/Medicare

Part A Medical Review(use appropriate mail code AG-232, AG-220, or AG-

230)

P.O. Box 100238

Columbia, SC 29202-3238

ADR

For FedEx, Airborne or UPS:Palmetto GBA

Medicare Part A Medical Review

Building One(use appropriate mail code AG-232, AG-220, or AG-

230)

2300 Springdale Drive

Camden, South Carolina 29020

ADR

Do not send correspondence intended for other Palmetto GBA departments with your ADRs

Do not send packages C.O.D.

Submit all documentation with the original ADR response

Subsequent documentation may not reach the Medical Review department prior to the payment decision

ADR

ADRs are not forwarded by the postal service

When your facility has a change of address, and submits an 855A to CMS, it may take some time before the change is posted in FISS

ADR

Non-receipt of requested copies of medical records

• Requirement of participation in the Medicare program as indicated in the 42 CFR Part 424, Section 424.5 and 42 CFR Part 489, Section 489.53

• This remains one of the top denial reasons across all lines of business

ADR

When the requested documentation needed to make a medical review determination is not received timely, a medical review determination is made based on the available medical information

When no records are received by the 46th day, the claim will be denied with reason code 56900

ADRRequesting a Reopen of a 56900 Denial:

• 120 days from the date of the denial to submit a request for a reopen

• Submit the requested documentation to the address on the ADR with a letter requesting a reopen

• Claim will be reviewed and an adjustment made in the 56900 decision

• Monitor Remittance Advice (RA) for outcome of reopen

• Provider notified by medical review of re-open results only when the claim is fully/partially denied or re-coded

CERT Program The CERT program is a federally mandated program

that produces national, contractor-specific, and service-specific paid claim error rates, as well as a provider compliance error rate

The provider compliance error rate is a measure of the extent to which providers are submitting claims correctly

The goal of the CERT program is to measure and improve the quality and accuracy of Medicare claim submission, processing, and payment

CERT Program

The CERT program has two components• The CERT Documentation Contractor

(CDC) requests and receives medical records

• The CERT Review Contractor (CRC) reviews all submitted records and shares the claim review decision with the FI

CERT Program

The FI makes any necessary adjustments to the claim based on the CERT determination

Provider notification of any change in the original decision is through the remittance advice

CERT Program

Visit www.PalmettoGBA.com home page under Helpful Information

Select CERT for access to the followingCERT Fact Sheet (in handout)CERT Flow ChartCERT NewslettersCERT Articles

Summary of Documentation Requests

Signed Notice of Election

Signed physician’s certification to cover the dates of service billed

Statement when the hospice medical director is the attending physician

Plan of care pertinent to the dates of service billed

Summary of Documentation Requests

Documentation to substantiate terminality and medical necessity

If beneficiary has expired, submit information regarding date and cause of death

Level of Appeals

Five levels• Redetermination – Fiscal Intermediary• Reconsideration – Qualified Independent

Contractor (QIC)• Administrative Law Judge Hearing – Office

of Medicare Hearings and Appeals• Departmental Appeals Board• U. S. District Court

Part A Appeals Address

Medicare Part A RedeterminationMail Code: AG-630P.O. Box 100238Columbia, SC 29202-3238

Medicare Part ARedeterminationMail Code: AG-6302300 Springdale Dr.Camden, SC 29021

OR

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