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Welcome to the Novitas Solutions 2015 Symposium

July – September 2015

Disclaimer

• All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

• The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

• Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

• Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

• This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

• Novitas Solutions does not permit videotaping or audio recording of training events.

Agenda

• Introduction • Comprehensive Error Rate Testing

Program • Novitas Initiatives

o Website o Upcoming Education o Self-Service Options

Objectives

• Discuss the impact of the CERT program on Medicare providers – emphasizing compliance plan application

• Introduce new and upcoming Novitas Solutions initiatives to aid providers in staying current with Medicare changes

• Review important upcoming provider education

Acronym List

Acronym Definition CERT Comprehensive Error Rate Testing

CMS Center for Medicare & Medicaid Services OIG Office Inspector General PSC Program Safeguard Contractor ZPIC Zone Program Integrity Contractor

Introductions

Comprehensive Error Rate Testing (CERT)

Background

• The Centers for Medicare & Medicaid Services (CMS) is required to protect the Medicare Trust Fund

• CMS contracts with various contractors to perform prepayment and post payment reviews of claims through various Medicare review programs o Comprehensive Error Rate Testing (CERT) Program o Medical Review through the Medicare Administrative Contractors

(MACs) o National Correct Coding Initiative (NCCI) Edits o Medically Unlikely Edits (MUE) o Recovery Audit (RA) Program o Program Safeguard Contractors (PSC) and Zone Program

Integrity Contractors (ZPICs) o Office of Inspector General (OIG)

Comprehensive Error Rate Testing (CERT)

• What is it? A program developed by Centers for Medicare & Medicaid Services (CMS) to randomly audit claims monthly to determine if they processed correctly

• Why does it matter? To protect the Medicare trust fund and determine error rates nationally and regionally

• Who is involved? You. A request for medical records from AdvanceMed alerts you that one of your claims has been selected as part of the monthly random sample

• How does it work? A letter will be sent to your office requesting the medical documentation. You need to comply in a timely manner with the request

• JH o http://www.novitas-solutions.com/webcenter/spaces/CERT_JH

JH Part A DRG - Key Points

• Documentation not supporting diagnosis reported on claim o Incorrect diagnosis code reported o Order of diagnosis codes submitted on claims o Incorrect present on admission identifier

• Documentation not supporting medical necessity o Patient history o Use of recent conservative measures prior to preforming

procedure to include type, duration, and results • Physician documentation is key to supporting

diagnosis and procedures performed

CERT Appeals vs. Claim Adjustments

• We are instructing providers to cease the practice of cancelling and adjusting claims that are selected in the CERT review process o Notify CERT if an error has been made on the claim DO

NOT cancel or adjust claims • When the CERT adjustment has been made in the

FISS system, it will appear as an XXH Bill Type o Once finalized, proper appeals process should be followed

to appeal CERT related claims • Article

o http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00003498

JH Part B – Key Points

• Documentation not supporting level of service billed on claim o One or more of key components not documented to

appropriate level o Non-physician practitioner and physician shared visits not

appropriately documented • Signatures

o Illegible signatures with no attestation statement o Missing signatures on documentation

• Lab Tests o No documentation submitted to support medical necessity

for ordered test

Medical Review (MR) Activity • Novitas Solutions’ MR Department is one component of the overall

Medicare Integrity Program (MIP) • Typically, MR conducts the following review types

o Probe (pre or post payment) Service-wide

– Typically 50-100 claims Provider-specific

– Typically 20-40 claims

o Audit/Edit (pre or post payment) Service-wide Provider-specific

• Data analysis performed o Verified and context provided

• Claim review performed o Prepayment or post payment

• Referral to appropriate entity when fraud detected

Recovery Audit (RA) Program

• Identify and correct Medicare improper payments through the detection and collection of overpayments

• Centers for Medicare & Medicaid Services webpage o http://www.cms.gov/Research-Statistics-Data-

and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program

• Connolly, Inc. o http://www.connolly.com

PSC and ZPIC

• Program Safeguard Contractor (PSC) and Zone Program Integrity Contractors (ZPIC) Major Responsibilities are o Indentify and deter Medicare fraud and abuse o Develop fraud cases to refer to OIG o Support law enforcement o Identify and report program vulnerabilities to CMS o Recommendations for provider education,

overpayment recovery, corrective actions, and licensure considerations

Office Inspector General (OIG)

• OIG Work Plan outlines their current focus areas and states the primary objectives of each project

• Specific Items Include o Inpatient Billing for Medicare Beneficiary o Same Day Readmission o Compliance with Medicare Transfer Policy o Place of Service

• https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Stay Compliant

• Conduct internal monitoring and auditing • Implement compliance and practice standards • Designate a compliance officer or contact person • Conduct appropriate training and education • Respond appropriately to detected offenses and develop corrective

actions • Develop open lines of communication with employees • Enforce disciplinary standards through well-publicized guidelines • Accurate coding and billing • Maintain accurate and complete medical documentation • Stay current with Medicare rules and regulations • Respond promptly and completely to Medicare inquiries • Use good business sense

Website Features Novitas Initiatives

Website Improvements

• Based on your feedback we continue to update our website

• Recent Improvements o Better Page Navigation o Major Performance Upgrades o Page Titles o Minor enhancements to web search o Rolling banner o Website Navigation Video https://www.youtube.com/watch?v=JQwXOJt1YeA

Website Satisfaction Surveys

Novitas Home Page

JH Customized Content

JH Part A Home Page

JH Part B Home Page

Novitasphere Help Desk 1-855-880-8424

What is Novitasphere? • Novitasphere is our free web-based Portal that will allow providers access to Eligibility,

Claim Information and Remittance Advice, Claim Submission with File Status, Electronic Remittance Advice (ERA), Claim Correction, and MailBox

• Novitasphere is available to the Jurisdiction H and Jurisdiction L Part B Provider

Community • Visit the Learning Management System to Register for all of demonstrations being offered

for Novitasphere • More Information on Novitasphere can be located on our website

o www.novitas-solutions.com • or by accessing the link below

o http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00081055

• Novitasphere will soon be available for Billing Services and Clearinghouses that service

Part B practitioners! o Coming September 2015 o Stay tuned for EDI Mailing List Messages regarding testing and enrollment

Novitasphere Registration

• Step 1: Determine who the Provider Office Approver, or primary person from your office, who will be responsible for accessing the application

• Step 2: Complete the Electronic Data Interchange (EDI) Portal Enrollment form (8292P/8292PJH) found in the Enrollment section of the Novitasphere Center of our website o Fax the completed form to 1-877-439-5479

• Step 3: Once the EDI enrollment form is approved, you will

receive instructions to apply for a User ID for the Provider Office Approver, and the required next steps to set up access for your organization and End Users

Novitasphere Claim Correction Feature • Save your office valuable time with this great Novitasphere feature! • It’s free, quick, easy, and secure to do on-line with no need to call

our Claim Correction line! • The following common clerical errors can be corrected on finalized

claims through the Novitasphere Claim Correction feature o Number of services or units o Diagnosis code (Primary) o Eligible modifiers o Procedure code o Date of service o Place of service o Billed amount

• Novitasphere Claims Correction Guide o http://novitas-

solutions.com/cs/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&dDocName=00086496&allowInterrupt=1

Upcoming Education Novitas Initiatives

Novitas Medicare Learning Center

• Features o Create an individualized education account o Register for webinars, teleconferences, and workshops o Download your Continuing Education Unit (CEU) Certificates o Be placed on a waitlist if the educational event you register for is closed

• Benefits o Centralized location for all educational materials o Track all of the educational events you’ve attended o Access Medicare education 24 hours a day, 7 days a week with web-

based training modules • JH

o http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00081812

Calendar of Events

• Our Education and Training Center offers a wide variety of education

• Join us for Workshops, Teleconferences, and Webinars

• The most current calendar of events o JH Part A

http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00084381

o JH Part B http://www.novitas-

solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00084382

Stay Up-to-Date

• Electronic Mailing List o Daily E-mail of the latest Medicare Updates o New streamlined design newsletter format o Subscribe JH

http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00007968

• Podcast o Podcast of the latest Medicare Updates and other informative topics o http://www.novitas-

solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00025071

• Educational Videos and Tutorials o http://www.novitas-

solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00082787

Self-Service Options Novitas Initiatives

Jurisdiction H Customer Contact Information

• Provider o 1-855-252-8782 o Hours of Operation, Central Time (CT)/Mountain Time (MT)

Monday - Friday: 8:00 am – 4:00 pm CT/MT

• Interactive Voice Response (IVR) o Hours of Operation

Eligibility and General Information – 24 Hours a day 7 Days a week

Full IVR Options – Mondays: 5:00 am – 7:00 pm CT – Tuesday – Friday: 3:00 am – 7:00 pm CT – Saturdays: 5:00 am – 3:00 pm CT

o Step-by-Step Guide JH Part A

– http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004409 JH Part B

– http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004421

Beneficiary Contact Information

• Patient / Medicare Beneficiary o 1-800-MEDICARE (1-800-633-4227) http://www.medicare.gov/index.html

Fiscal Intermediary Standard System (FISS) Hours

• Colorado (CO), New Mexico (NM), Oklahoma (OK), Texas (TX) o Monday – Friday

6 am – 8pm, Central Time (CT) o Saturdays

6 am – 3pm CT

• Arkansas (AR), Louisiana (LA), Mississippi (MS) o Monday – Friday

6 am – 7pm CT o Saturdays

6 am – 3pm CT

Termination of the Common Working File - Delayed

• The HIPAA (Health Insurance Portability and Accountability Act) Eligibility Transaction System (HETS) will replace Common Working File (CWF) eligibility inquiries o Access to Health Insurance Query Access (HIQA) and CWF

inquiry menu option 10 will be terminated • For more information

o MLN Matters Article MM8248 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM8248.pdf o Special Edition Article SE1249

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1249.pdf

Centers for Medicare & Medicaid Services (CMS)

• The CMS website offers valuable resources such as o CMS Internet Only Manuals (IOMs) o Medicare Learning Network (MLN) Matters

Articles o Open Door Forum

• http://www.cms.gov/

Thank you and enjoy your day! Greg Hart Supervisor, Outreach and Education