Transition of Inpatient Hospital Review Workload

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Transition of Inpatient Hospital Review Workload
An Overview of Changes to the Review of Acute
Inpatient Prospective Payment System (IPPS)
Hospital and Long Term Care Hospital (LTCH)
Claims

• Office of Financial Management
• Program Integrity Group
• Date June 2008

Also includes claims from any hospital that
would be subject to the IPPS or LTCH PPS had it
not been granted a waiver
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Outline

• The Old Environment
• The New Environment
• Roles under the New Environment
• Why the Change?
• When will the Transition occur?
• What will be Different?
• What will be the Same?

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Acute IPPS Hospital and LTCH Claim Review The
Old Environment

• In the past, QIO1 responsibility included
• Hospital Payment Monitoring Program (HPMP)
  reviews
• Conducting utilization reviews for payment
  purposes
• Measurement of the accuracy of Medicare FFS
  payments for short- and long-term acute care
  hospitals
• Quality of care reviews to ensure that care
  provided to Medicare beneficiaries meets
  professionally recognized standards of healthcare
• Performance of provider-requested higher-weighted
  DRG reviews
• Review of Emergency Medical Treatment Active
  Labor Act (EMTALA) cases
• Performance of Expedited Determinations
• Medicare Part A claims processing contractors,
  called FIs2 and MACs3 had no acute care inpatient
  hospital claim review responsibility
• CERT4 program had no acute care inpatient
  hospital claims improper payment measurement
  responsibility

1 Quality Improvement Organizations 2
Fiscal Intermediaries 3 Medicare
Administrative Contractors 4 Comprehensive
Error Rate Testing
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Acute IPPS Hospital and LTCH Claim Review The
New Environment

• QIOs will focus their efforts on quality
  improvement and continue to perform quality
  reviews, certain utilization reviews, such as,
  provider-requested higher-weighted DRG and EMTALA
  reviews, and expedited determinations.5
• FIs and MACs will perform most utilization
  reviews of acute care inpatient hospital claims
• CERT will measure the inpatient hospital paid
  claims error rate

5 The QIO 9th Statement of Work provides a full
listing of activities and is available at
http//www.cms.hhs.gov/QualityIMprovementOrgs/04_9
thsow.asp
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Acute IPPS Hospital and LTCH Claim ReviewWhy
the Change?

• CMS initiated the change in response to
  recommendations by OIG6
• and the Institute of Medicine7
• There are 3 primary benefits to the transition
• Consistency
• Acute long- and short-term hospitals have been
  the only Medicare Fee For Service (FFS) settings
  not reviewed by FIs and MACs
• These hospitals have been the only settings not
  included in the CERT error rate measurement
• Efficiency
• The entities that process claims will be
  responsible for preventing improper payments
• We anticipate the new strategy will be more cost
  effective since fewer contractors will be
  conducting the non-quality reviews
• Mitigation of the Perception of a Potential
  Conflict of Interest
• There is the perception of a potential conflict
  of interest created by having the QIOs measure
  the payment error rate for claims on which they
  themselves made payment determinations.
• The transition will enable QIOs to focus efforts
  on quality improvement and maintenance.

6 Office of Inspector General Report Oversight
and Evaluation of the Fiscal Year 2005
Comprehensive Error Rate Testing Program
(A-03-05-00006) (http//oig.hhs.gov/oas/reports/r
egion3/30500006.pdf) 7 Institute of Medicine
Report Medicares Quality Improvement
Organization Program, Maximizing Potential
(http//www.iom.edu/CMS/3809/19805/33411.aspx)
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Acute Care Inpatient Hospital Claim ReviewWhen
will the transition occur?

• CERT began reviewing acute care hospital claims
  for improper payment measurement in April 2008
• This corresponds with the beginning of the
  November 2009 Medicare FFS Improper payment
  report period.
• CERT will review claims submitted April 1, 2008
  forward
• We anticipate FIs and MACs will begin performing
  reviews on acute care inpatient hospital claims
  for improper payment prevention/reduction in the
  Summer 2008
• FIs and MACs would be allowed to review claims
  submitted January 1, 2008 forward.

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Acute IPPS Hospital and LTCH Claim Review How
will reviews be different?
Because of varying statutory requirements, the
FI/MAC, CERT, and QIO review procedures differ.
The review procedures for acute inpatient
hospital claims will be consistent with the
procedures used by FIs/MACs and CERT for review
of outpatient hospital claims and all other
Medicare FFS claims.

• Claim Selection
• After the first phase of review, FIs/MACs will
  perform targeted medical review, based on data
  analysis, not random review like QIOs have done.
• During the first phase, FIs/MACs will have the
  option to perform targeted or random medical
  review.
• FIs/MACs can perform medical review on a
  prepayment OR postpayment basis, unlike QIOs who
  only performed postpayment review
• CERT performs random reviews and utilizes
  different sampling, review, and calculation
  methodologies than those used by the QIOs to
  establish and report an error rate. Because of
  the difference in approach, CERT error rates will
  not be comparable to previous QIO-calculated
  error rates.

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Acute IPPS Hospital and LTCH Claim Review How
will reviews be different? (cont)

• Medical Record Requests
• The CERT Documentation Contractor will notify
  providers that claims have been selected for CERT
  review via letter or telephone contact.
• The medical record request letter will be mailed
  or faxed according to the hospitals preference
• Hospitals may submit medical records via mail or
  fax. The CERT Documentation Contractor also
  accepts CDs with imaged medical records.
• The FIs and MACs will send an automated letter or
  provide instructions for how to access FISS (the
  claims processing system) for Additional
  Documentation Requests (ADRs).  Providers may use
  the claim inquiry screen in Direct Data Entry
  (DDE) to verify the status of claims suspended
  for medical review, as they currently do for
  outpatient claims and other types of claims.
• Hospitals submit hardcopy medical records via
  mail

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Acute IPPS Hospital and LTCH Claim ReviewHow
will Reviews be Different? (cont)

• Physician Involvement in Reviews
• As with any claim reviewed by FIs/MACs or CERT,
  physicians will be utilized in acute inpatient
  hospital claim review to the extent that it is
  necessary. Qualified clinicians, such as nurses
  and therapists, will perform the reviews,
  consulting with physicians or other specialists
  as needed.
• Reimbursement for Photocopy Costs
• Neither CERT nor the FIs/MACs reimburse for
  photocopying expenses for medical record
  requested from any setting.
• Appeals
• Appeals of claim denials will occur after the
  payment denial is issued. Like all other
  Medicare claims, providers and beneficiaries will
  have appeal rights.

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Acute IPPS Hospital and LTCH Claim ReviewWhat
will Remain the Same?

• Review Criteria
• The coverage and payment guidelines used by
  FIs/MACs and CERT will be the same as used in the
  past by QIOs.
• Like the QIOs, FIs/MACs will adhere to CMS
  national policy and contractor local coverage
  determinations (LCDs) in making payment
  decisions.
• FI/MAC reviewers will utilize clinical judgment
  in making payment determinations, as the QIOs
  did.
• Use of Screening Tool
• We anticipate that FIs/MACs and the CERT
  contractor will continue to use a screening tool
  for claims review, before making a determination
  on an individual claim basis. Like QIOs,
  FIs/MACs will not be required to use a specific
  tool.

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Acute IPPS Hospital and LTCH Claim Review
Comparison At a Glance
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Acute IPPS Hospital and LTCH Claim Review Roles
of Review Entities in the New Environment
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Information About the CERT Program and FI/MAC
Review Process

• CERT Fact Sheet www.cms.hhs.gov/MLNProducts/downl
  oads/certfactsheetv1-3.pdf
• Medicare FFS Improper Payment reports
  www.cms.hhs.gov/CERT
• CERT Documentation Contractor website
  www.certprovider.org

• Medical Review Fact Sheet (being revised)
  www.cms.hhs.gov/MedicalReviewProcess/Downloads/mrf
  actsheet.pdf
• Program Integrity Manual Publication 100-08
  http//www.cms.hhs.gov/Manuals/IOM/list.asp

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Questions?