In 2023, regulators re-instituted audits of facilities for inappropriate diagnoses of schizophrenia (justification for anti-psychotic use), plus a five-claim audit of every nursing home. The purpose of the audit was to address a long-standing concern that inappropriate coding was driving higher Medicare reimbursement under PDPM, despite documentation in patient records, not substantiating the level of care required or provided. More on the five claim audits from 2023 is available via previous posts, below.
- https://rhislop3.com/2023/06/01/snfs-get-ready-claims-audits-start-soon/
- https://rhislop3.com/2023/08/24/snf-claims-audits-so-far-messy/
To date, Medicare/CMS has not shared much detail about what it has found as a result of the five claim audits. Anecdotally, I am hearing that the process has been rather messy, inconsistent, and providers are still uncertain as to how the audit contractors are determining their communicate results.
CMS came under scrutiny last summer. The Government Accountability Office (GAO) said CMS needed to improve its process of recouping overpayments via state Medicaid programs citing “lenient” processes that let states opt out of the federal auditing program. For providers, this means that Medicaid payments now are likely to be subject to audits in 2024.
Last year, spring, I posted the RAC audit elements list for providers. The list is available here, and the SNF elements are highlighted. RAC approved_issues_list_04_12_2023
One of the risk areas for providers in terms of Medicaid is the move to state agency implementation of PDGM methodology for Medicaid reimbursement. For many providers, Medicare is not as big of a risk area due to low to in some cases, almost no Medicare cases. Rural SNFs for example, may see scant few Medicare claims for SNF care, perhaps only a handful each year. Medicaid, however, may represent the bulk of their census days (payer mix). PDGM brings forth an increased data set for auditors to identify claim anomalies.
Medicare post-acute providers (all Medicare providers) are required to have an Ethics and Compliance program. Meeting the requirement for SNFs and post-acute providers requires the following elements to be in-place.
- Written policies, procedures and standards of conduct.
- Designation of a compliance officer and compliance committee.
- Conducting effective training and education programs, ongoing. New employees must be trained and existing employees, need reminder training annually. If a compliance issue arises, training may be an element to remediation plans.
- Developing effective lines of communication for reporting suspected compliance breeches. This includes a reporting system that is anonymous and secure.
- Enforcing standards through well‐publicized disciplinary guidelines that specify how, if an issue arises, investigation will occur, and accountability will be handled.
- Conducting internal monitoring and auditing tasks to assure compliance. This is the primary job, along with education, of the compliance officer.
- Responding promptly to detected violations and how corrective action will occur and be monitored.
The Federal Condition of Participation pertaining to the Ethics and Compliance requirements is available here; ComplianceandEthics 483.85
My approach to the compliance tasks and meeting the requirements is to not separate processes or focus on paper compliance. I look at compliance as an integral operating process that SNFs can utilize to accomplish a number of tasks (requirements) collectively. In other words, the code lays out the elements required but not the HOW. The how can be accomplished a number of different ways and creativity, can be an SNFs best friend.
Below is the approach I advise SNFs to consider. For more information or tools, etc., comment to this post or drop me a message at rhislop@h2healthllc.com. I’m happy to work with SNFs to implement a virtual compliance program that meets all requirements and yet, saves the SNF significant dollars in terms of separate needs for example, for a designated employee as a compliance officer (e.g., compliance officer comp. easily $100k per year, versus a robust virtual program at $5 K to $10K per year).
- Integrate compliance as an element of QAPI. Use tools such as Triple Check, Clinical Review, monthly QAPI meeting dashboards with specific monitoring requirements, to identify risk areas.
- Use QAPI plans as elements of correction action for compliance. Also, use formularies and algorithms/pathways as tools to minimize billing vs. documentation risks.
- Staff education should include compliance requirements but moreover, should incorporate the QAPI approach, not compliance as a separate condition, per se.
- Utilize patient/resident satisfaction programs as a means of reporting. Don’t have these in-place? Pretty easy to develop an email, website link, and toll-free number to collect information, including complaints or reports or compliance violations.
- Audits, and absolutely, for effective compliance, require an external agency that is expert on Medicare SNF claims, PDPM, MDS/RAI, to include,
- Claims sampled randomly testing Medicare level/PDPM billed against the MDs and against clinical documentation.
- MDS audits that look specifically at what was coded/developed vs. what was billed.
- Claims audits based on risks identified via QAPI process (falls, wounds, mediation errors, etc.).
- Audits should achieve a number of different performance improvement conditions.
- Surety in claims processing. If RAC audits occur, the compliance audit processes conducted by the SNF provide security and procedural responses that minimize RAC implications.
- Claims accuracy and potential, opportunities for additional revenue – revenue integrity and maximization opportunities.
- Education for staff on documentation, coding, etc.
- Data to inform QA and survey/certification preparation.
- Litigation risk reduction.
- Liability insurance benefits in the form of renewals and premium savings. Providers that have robust QAPI and Compliance programs are better risks and today, receive preferential pricing and terms.
Providers/organizations that are looking to improve their Ethics and Compliance programs, save money and increase QAPI, claims, and performance improvement, go ahead and comment to this post or drop me a note at rhislop@h2healthllc.com. I can definitely help!