RACs, MACs and MICs

Proactive Strategies for Home Health Care

 Define Roles and Focus of Audit Groups
 Identify key areas of Medicare Policy Benefit
Manual, Chapter 7 essential to the home health
clinician
 Identify specific strategies to promote best
practices and minimize interaction potential
with RACs, Macs, and ZPics

 4.5 million claims per work day
 574,000 claims per hour
 9,579 claims per minute
 Is it any wonder there is concern regarding
fraud and abuse?

 “Accuracy of coding and claims for Medicare HHRGs:
We will review Medicare claims submitted by HHAs to
determine the extent in which the HHRG billing codes
that are used in determining payments of home health
agencies are accurate and supported by documentation in
the medical record. The Social Security Act 1895, governs
the payment basis and reimbursement for claims submitted
by HHAs including a case-mix adjustment using HHRGs.
Medicare pays for home health episodes based on a PPS that
categorizes beneficiaries into groups, referred to as HHRGs.
Each HHRG has an assigned weight that affects the payment
rate. We will assess the accuracy of HHRG assignment
and identify patterns of coding by HHAs.
Remember that HHAs refers to home health agencies

 Medicare Prescription Drug, Improvement, and
Modernization Act (MMA)
 Tax Relief and Health Care Act of 2006 (TRHCA)
 TRHCA section 306 gave CMS authority to make
recovery audit contractors (RACs) a permanent
nationwide program and the establishment of the
nationwide Program Safeguard Contractors (PSCs)
to fight fraud with data analysis

 Focus on Hospitals and Physician Practices
 In only six states, recovered over $1.6 Billion
 Incorrectly coded: 35%
 Medically unnecessary: 40%
 Insufficient documentation: 10%

Per FI NGS, “The RACs detect and correct past
improper payments so that CMS and carriers, fiscal
intermediaries (FIs) and Medicare Administrative
Contractors (MACs) can implement actions that will
prevent future improper payments”
 RACs can only review discharged records
 Cannot review records already reviewed by other
entities
 Home Health, Hospice, and DME now have a RAC
exclusive for them!

 RACs are paid contingency fees from 9.9%-12%
 Can reopen claims up to three years from date claim
was paid
 Required to follow all CMS payment policies
 Required to have a medical director on staff with
audits teams to include RNs, therapists, and coders
 Annual accuracy rates are to be publically stated

 Region A:
Connecticut, Delaware, Maine, Maryland, Massachusetts, New York, New Jersey,
Pennsylvania, Rhode Island, and New York
 Region B:
Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin
 Region C:
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North
Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia
 Region D:
Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska,
Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming

 Services are medically unnecessary or there is delayed
implementation (Focus: Therapy)
 Patients are not Homebound
 Services are incorrectly coded and sequenced
 Failure to provide claim supportive
documentation
 Duplicate claims submitted
 Medicare secondary pay or improper payments
 Lack of order centricity

 Medicare Benefit Policy Manual- Home bound status
 Homebound status may be an issue with certain records. CMS defines
homebound status as:
 Confined to the home – Describe why the patient is homebound. An
individual is considered “confined to the home” if both of the following two
criteria are met:
 Criteria 1--The patient must either:
 Because of illness or injury, need supportive devices such as crutches, canes,
wheelchairs, and walkers; special transportation; or another person’s help to
leave his or her residence, OR
 Have a condition such that leaving his or her home is medically
contraindicated
 Criteria 2--There must exist:
 A normal inability to leave home; AND
 Exertion of a considerable and taxing effort needed to
leave the home.
 (Medicare Benefits Policy Manual Chapter 7 Home Health Services, MBPM
Chapter 7

 Skilled Services-
 Per CMS Medicare Benefit Policy Manual, Chapter 7:
 “A service that is ordinarily considered nonskilled could be
considered a skilled therapy service in cases in which there is clear
documentation that, because of special medical complications,
skilled rehabilitation personnel are required to perform the
service. However, the importance of a particular service to a
patient or the frequency with which it must be performed does
not, by itself, make a nonskilled service into a skilled service.”
 If a chronic diagnosis is the primary reason for ongoing care, the
skilled nurse or therapist should be VERY clear as to why (s)he is
still making visits.
 If visit notes do not EACH stand alone and justify care, the nurses
or therapist’s visits are at risk.

 Teaching-
 MBPM Chapter 7 states:
 Teaching & Training activities that require skilled nursing personnel
to teach a patient, the patient’s family, or caregivers how to manage
the treatment regimen would constitute skilled nursing services.
 Where the teaching or training is reasonable and necessary to the
treatment of the illness or injury, skilled nursing visits for teaching
would be covered.
 When is teaching & training no longer covered?
 Where it becomes apparent after a reasonable period of time that the
patient, family, or caregiver will not or is not able to be trained, then
further teaching and training would cease to be reasonable and
necessary.
 The reason why the training was unsuccessful should be documented
in the record.

 There are essentially three types of teaching:
 Initial Teaching of a patient requires instruction on a new
order, new medication, new diagnosis. The specifics should
be clearly stated,, if a med change or new med, what
specifically was taught as to the administration of the med
and how it impacts upon the disease process.
 Reinforced Teaching requires teaching/instruction on
something the patient and/or caregiver may be
knowledgeable of, but needs additional teaching.
 Re-teaching involves evaluation and reinstruction on a
medication, diagnosis, treatment, etc that the patient or
caregiver has had prior instruction.
 What was to be taught, how it would be taught, how the
clinician knew there was learning does not appear to be
clearly delineated within several of the records.

 Congruency Congruency Congruency
 Therapists use many tests to measure baseline and
progress. Be certain the same test is used to
demonstrate progress or regression.
 Objective data/documentation supports findings
throughout the episode.
 Protect your dollars…have objective supportive data
for findings.
 Five denied visits out of 24 billed can mean a loss of
approximately $1200.00

 Prior to 2008, the more than 50% of high therapy
cases ended with 10-13 visits
 With the move to the tier model in 2010, this group
has declined and significant growth has occurred in:
 6-9 visits
 14-19 visits
 20+ visits

 Full or partial denial because the clinical
documentation:
Did not support the medical necessity of the skilled
services billed
Did not demonstrate a reasonable potential for
change (improvement) in the medical condition or
Sufficient time had been allowed for teaching or
observation of response to treatment in prior
episodes of care.

 How many therapy visits are you averaging per
episode? Percentage of patients receiving therapy?
 Of the patients who receive therapy, what is the
distribution (%) across the ranges?
 How does your agency compare with your peers
regionally or nationally?
 Do response levels on functional M items correlate
with therapy referrals? High-Low levels of
impairment?

 Do therapy treatment plans and progress notes have:
Clear functional goal statements?
Document progress toward goals objectively?
 How is care coordinated among therapists? Among all
disciplines?
 How can you support “reasonableness and medical
necessity?”
What is the patient treatment: diagnoses? Restoration/maintenance of
function affected by illness? Frequency and duration of services
consistent with home care client’s: medical history, disease, prior to end
of episode level of function, and risk identification.

 Is therapy consistent with the nature and severity
of the condition?
 Therapy services must be provided, expecting that
the condition of the patient will improve in a
reasonable period of time.
 Documentation of medical necessity should be
documented through evaluation, treatment plan, and
progress notes.
 Has your agency identified high risk diagnosis,
number of visits, or number of episodes?

 RACS are paid on a contingency fee basis
 Focus: High dollar improper payments with highest return
for RACS (for dollars invested)
 Belief is that Coding, Homebound status, Therapy use,
Wound Care, Co-Morbidities, and Medical necessity will
be scrutinized
 RACS must pay back contingency fees if they lose appeals
 RAC program to cost .22 cents for each dollar returned
to the trust funds (Based on RAC performance with
Hospitals)

 Medicare Administrative Contractors have replaced fiscal
intermediaries.
 January, 2009 CMS announced the awarding of the final
MAC contracts to a total of 15 companies. Each now has a
jurisdiction.
 California is in district 1 and New York is in jurisdiction 13.
 MACs have been transitioning in and replacing the Regional
Home Health Intermediaries (RHHIs) They can act with
RACs.
 Of the 15 MACS, 4 will service only DME claims
 CMS has assigned agencies that provide Home Health AND
Hospice to four “specialty” MACs (regions 1, 6,11,14,15)
 Auditing claims and making coverage determinations more
quickly is the ultimate goal and remains same in 2014

 While agencies worry about RACs, Remember,
a MAC can place an agency on focused review
for a year, if it identifies potential cause.
 Answer ADRs promptly!

 MICs Medicaid Integrity Contractors
 MICs are expected to complete four program
integrity activities:
1. Review provider actions
2. Audit claims
3. Identify overpayments
4. Educate providers, managed care providers,
beneficiaries, and others with respect to payment
integrity and quality of care

 Program Integrity efforts target Medicare and
Medicaid Individually as well as Medi-Medi
 MICs have been labeled as the “RACs for
Medicaid”
 MICs are not paid by contingency fee but fee for
service
 Renewal of MIC contract is based on successful
performance
 Dollars identified or recovered are not tied to
compensation of the MICs
 MICs must comply with state-imposed
requirements

 ZPICs will perform Medicare Program integrity
functions for CMS
 Each MAC will interact with one ZPIC to handle
fraud and abuse issues within their jurisdictions
 ZPICs are seen to consolidate work of present CMS
Program Safeguard Contractors (PSCs) and
Medicare Drug Integrity Contractors (MEDICs)
 ZPICs are divided into 7 zones.

 Bill Dombi, Chief Legal Representative for NAHC
stated (4/20/2010), “If an agency receives a Z-PIC
letter, they should just call their legal counsel”
 The RACs act with the Department of Justice and
FBI as the investigators when fraud is very strongly
thought to have been found. When the ZPICs notify
an agency, they have already discerned an issue.

 The more aggressive investigator of essentially
DME and HH
 Expansion of DOJ/CMS/HHS Inspector General
Medical Strike forces to Baton Rouge, Brooklyn,
Detroit, Houston, LA, Miami-Dade, McAllen, TX,
and Tampa Bay
 Using state of the art technology to expand the
CMS Medicaid and Medicare provider audit
program
 This program leadership has meetings with top
anti-fraud leaders in Congress/Law
enforcement/Private sector

 “Providing additional resources to our civil
enforcement efforts under the False Claims Act
to increase dollars recovered; data sharing,
including access to real time data; detect
patterns of fraud through technology;
strengthening partnerships among Federal
agencies between public and private sectors.”
CMS

Consumer Assessment of Healthcare
Providers and Systems (CAHPS)

Readying for P4P
Looking at patient /beneficiary outcomes
Assessing beneficiary satisfaction

 Why has CMS moved to CAHPS?
Measure patient perception of care- Are
consumers happy with the home care they
received?
Component of Home Health Quality Initiative
(HHQI)
Place in public domain for beneficiary informed
decision
Possible component of P4P

 Similar in that they will rate providers
 CAHPS asks patients to report experiences
 Focus: Aspects of care patients find important
Aspects of care patients can report on
CAHPS reports are specific, actionable, objective
36 questions re patient experience and characteristics
of care

Everything starts with a solid assessment,
congruent OASIS,
an individualized clinical careplan,
coding to the highest level of specificity,
and correct sequencing to drive the Plan of
Care:
the result is Proper payment

 Agencies must support services and care (NAHC,
2009, 2012)
 This starts with the correct tools
 This starts with excellent assessments and care
plans
 This starts with expert ICD-9-CM Coding…more
than just a coder…..a process…a process designed to
target weaknesses and build on strength

 With RACs, MACs, and ZPICs, increased scrutiny
abounds.
 Be certain visit documentation links to a documented
diagnosis.
 Are the OASIS answers congruent? How are you
verifying congruency of answers?
 Be certain there is coordination among the team.
 Therapy and Nursing activity must be connected to
specific functions, tests, and goals.
 Patient responses to treatments and interventions should
be clearly stated.
 Measurements of progress toward goals should be
clearly documented throughout the episode.

NEW NUMBERING
SYSTEM NUMBERING BY SYSTEM
 Tracking Items M0010-
M0150
 Clinical Record Items M0080-
 M0110
 Patient HX and Diagnoses
 M1000s
 Living Arrangements M1100
 Sensory Status M1200s
 Integumentary Status
 M1300s
 Respiratory Status M1400s
 Cardiac Status M1500s
 Elimination Status M1600s
 Neuro/Emotional/
Behaviorial Status M1700s
 ADLs/IADLs M1800s/M1900s
 Medications M2000s
 Care Management M2100s
 Therapy Need/POC M2200
 Emergent Care M2300
 Data collected at
Transfer/DC M2400s
 M0903 and M0906

 Is your billing process/system order centric?
 Be certain documentation is prompt, clear, concise
based upon realistic goals within realistic
timeframes…on each visit:
 Does each note specifically identify wound care, IV
administration, and flushes?
 Are education and patient teaching sessions clear
with patient responses and documentation of
progress or reevaluation need or completion?

Starts with a great tool, an experienced
well educated clinician and knowledge of
basics like…..

 CMS is promoting evidence-based care practices
 The conditions targeted by the new OASIS-C
process measures: diabetes, heart failure, pressure
ulcers
 Prevention oriented situations: falls and depression

Implementation of best practices:
diabetic foot care
pain management
influenza and pneumococcal vaccinations
risk assessments for pressure ulcers
risk assessments for depression
risk assessments for falls

 Care Processes mean the use of assessment tools
(included in a comprehensive assessment) or the
planning and delivery of specific clinical
interventions
 Several evidenced-based screening tools can be
considered “best practices” in home health. OASIS-C
includes data items to measure these processes.

It is all about your processes

 Measuring how customers (patients) view their
experience
 Inpatient and emergent care home health
assessments
 Functional status improvement
 Clinical symptoms assessment and change
 Pain assessment and intervention
 Education of patients and caregivers
 Patient care quality

 25 Process Measures in Total
 Represent 7 Domains: Timeliness of Care
 Assessment
 Care Planning
 Care Coordination
 Care Plan Implementation
 Education
 Prevention

1.Timely
Care
2. Assessment
3. Care Planning
4. Care
Coordination
6. Education
7. Prevention
5. Care Plan
Implementation

Date of referral and physician-ordered start of care (timeliness)
 Patient-specific parameters for physician notification (care coordination)
see M0102 and M104 below
 (NQF endorsed – will appear on Home Health Compare and
CASPER/OBQI)

 Physician Notification Guidelines Established
 Percentage of home health episodes of care in which the
physician ordered plan of care establishes limits for
notifying the physician of changes in patient status.
 Looking at how many episodes of care had a specific
date and how many started within 2 days of the referral
date.
 See the SOC/ROC M2250 Patient-specific parameters
for notifying physician plan of care
 Not NQF endorsed but will appear on CASPER
Reporting/OBQI

 Four Assessment measures
 All NQF endorsed and will appear on Home
Health Compare:
Depression Assessment
Multifactor Fall Risk Assessment
Pain Assessment
Pressure Ulcer Risk Assessment

Depression
Screening
M1730
NQF Endorsed

 If the answer is a 2 or a 3 or a 4?
 Do you have an algorithm?
 Do you have a psych nurse?
 Having a current prescription for a hypnotic
increases suicide risk by four times…..ABQAURP,
2012

 CMS is looking at the percentage of home
health episodes of care when patients were
screened by a standardized depression tool at
the SOC.

 So you have a psych team?
 Does your psych team include an OT?
Occupational Therapy is becoming a key
member on the team
 So much of therapy for depression requires healthy
displace of hostility.
 The RN therapist frequently uses words and
counseling.
 The Occupational therapist frequently uses
activities.

“sedative treatment was associated with nearly
fourteen-fold increase of suicide risk…”
www.biomedcentral.com/1471-2318/9/20

 OTs can assist with Stress Management and
 Self Awareness
 Anger and Conflict Management
 Self Esteem Building
 Basic Living Skills
 Relaxation Techniques
 Grief Counseling
The OT can assist, using various tools and activities
 The trained OT can use the Mini Mental status exam and the
Geriatric Mood Assessment

 Is the Geriatric Mood Assessment Tool one of
your approved tools?
 What other tools are you using or considering?
 Must all tools used be approved by agency
leadership?
 Even therapy tools?

Multi-Factor
Falls Risk
Assessment
M1910

 M1910- Multi-Factor Fall Risk Assessment
Falls history, multiple medications, mental impairment,
toileting frequency, general mobility/transferring
impairment, environmental hazards.
A good assessment is necessary as M2250 asks whether the
physician-ordered POC includes fall prevention
interventions. M2400 asks whether interventions to
prevent falls were ordered in the plan of care and
implemented.
 Falls Risk assessment, planning and interventions
(safety)
 So, after the assessment, what is the algorithm?

The Pain Assessment
M1240
NQF endorsed
M1242

 Domain:
 Formal pain assessment, pain interventions, and
pain management steps (effectiveness of care)
 Look at your agency SOC/ROC M01240 and M1242
and note how integrated assessment information is
sought.
 What information is collected ?

 Measuring pain using a standardized tool
 Measuring the patient’s acceptable pain level
 Let’s discuss the advantages of having an
acceptable pain level measurement.

Pressure-Ulcer
Assessment
M1300 (NQF Endorsed) -
M1324

M1300, M1302 risk of developing pressure ulcers
The clinician/agency will determine if a risk assessment was
performed and the patient has a risk
M1300 asks if the patient was assessed for risk of developing
pressure ulcer. If the answer is “yes” then the clinician is asked
if the assessment was based on an evaluation of mobility,
incontinence, and nutrition or using a standardized tool.
Many agencies use the standardized Braden or Norton Scale.
Remember, the answer “yes” can only be chosen when the
clinician completing the OASIS C assessment is also the
person completing the pressure ulcer assessment. OASIS Contractor,
NAHC Conference, 10/2011
M1302 asks what was concluded about the patient’s pressure ulcer
risk,

 Influenza and pneumococcal vaccines (population health
and prevention) is only collected at transfer RFA 6/7 but,
should this information be collected at the SOC/ROC RFA1/3
or on the Agency Referral form so it is readily available?
 The agency (You) will need a process to keep current on this
item. Perhaps, when recertifications are sent to the
physician, this question can be asked/clarified/verified?

 Two items focused on medication safety:
 M2002 Potential Medication Issues identified and
Timely Physician contact at SOC
 M2004 Potential Medication issues identified and
timely physician contact during the episode

Besides the present demographic and statistical data
collected: Name, address, phone, next of kin, DOB,
payor, recent hospitalizations, and medications…
Now, collect M0102 Date of Physician Order
M0104 Date of Referral
Status of Immunization
Previous Diagnoses and manifestations such as neuropathy,
CKD/ESRD, PVD, Peripheral circulatory, and
opthalmic conditions.
Procedure Codes
History of Pressure Ulcers

 In OASIS-C, CMS wants to include a way to measure an agency’s
use of evidence-based best practices…give good care after strong
assessment, screening, and care planning for predictable outcomes.
 Research shows that best practices assist to prevent exacerbation
of serious conditions. Agencies that do not invest in an education
EBP thinking may have significant difficulty with CMS and its
many audit arms.
 It is expected that processes of care implemented according to
evidence-based guidelines will ultimately lead to better clinical
outcomes.

 What will be your process following the
assessment?
 Will the clinician alone determine the CP and
POC?
 Do you have algorithms in place?
 When will you audit the care?
 How will you look at clinician productivity?
Individually? As part of a team?
 Do you have a billing audit tool in place?
 Do you have a RAC audit tool? Is there a
difference?

 Evidenced-Based decision making is based not
only on available evidence but also on patient
characteristics, situations, and preferences.
 Buyssess and Wesley have identified that
Evidenced Based Practices may be defined as
“treatment choices based not only on outcome
research but also on practice wisdom (the
experience of the clinician) and on family
values (the preference and assumptions of a
client and his or her family or subculture).


 We cannot lose site of the fact that good clinicians
want to care for their patients as they attain,
maintain, or recover optimal health.
 Assisting the clinician with tools to bridge the
span from assessment and SOC to Discharge and
planned outcomes becomes the daunting task.
 Quality care delivery and improvement
processes are co-existent with a solid bottom
line. It is establishing the proper process, for
each domain, that is the leader’s challenge. But
then, you are up to the task!

 Contact Susan Carmichael at:
 susanc@selectdata.com
 or call: Select Data
 714.524.2500 x235

RACs, MACs and MICs

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