BP - Health Care Compliance Association

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HCCA’s New Research Compliance Guide Research Compliance Professional’s Handbook The Practical Guide to Building and Maintaining a Clinical Research Compliance & Ethics Program Clinical research is highly regulated, so the role of compliance professionals is vital to meeting the demands of a wide range of governing entities. HCCA’s new reference manual, Research Compliance Professional’s Handbook, offers comprehensive, upto-date guidance to get you on the right track. Written by experts with hands-on experience in clinical research compliance, this book is intended for anyone with compliance duties or a need to understand such key areas as: Order Now • human subject protections • scientific misconduct • conflicts of interest • grant and trial accounting • effort reporting • privacy and security • clinical trial billing • records management • data monitoring committees • role of oversight entities • auditing & monitoring • integrating research compliance into corporate compliance Qty Cost HCCA Members ...................................$149.00 Non-members .....................................$169.00 Join HCCA! Non-members, add $200 and pay the member price for your order ................$200.00 (Regular dues $295/year) Please type or print: HCCA Member ID First Name M.I. Last Name Title Organization Street Address City State Zip Telephone Fax E-mail Mail check to: 6500 Barrie Road, Suite 250 Minneapolis, MN 55435 Fax order to: 952-988-0146 Total: $ My organization is tax exempt Check enclosed (payable to HCCA) Invoice me PO # Charge my: Mastercard VISA American Express Credit Card Account Number Credit Card Expiration Date Cardholder’s name Cardholder’s signature Prices subject to change without notice. HCCA is required to charge sales tax on purchases from Minnesota and Pennsylvania. Please calculate this in the cost of your order. The required sales tax in Pennsylvania is 7% and Minnesota is 6.5%. All purchases receive free FedEx Ground shipping within continental U.S. (Federal Tax ID: 23-2882664) 6500 Barrie Road, Suite 250 Minneapolis, MN 55435 Phone 888-580-8373 | Fax 952-988-0146 www.hcca-info.org | info@hcca-info.org
RAC demonstrations and inpatient rehabilitation – Vision of things to come? Editor’s note: Jane Snecinski is Principal at Noblis, Center for Health Innovation, headquartered in Falls Church, VA. Ms. Snecinski may be reached by e-mail at jane.snecinski@noblis.org for additional information. The past two years have proven to be very challenging for providers of rehabilitation services—both inpatient and outpatient. This article is one of two specifically written to focus on the compliance issues that have been brought into focus by the Recovery Audit Contractors (RACs). These issues have increased the financial risk for providers of rehabilitation services. This article specifically looks at the issues for providers of inpatient rehabilitation services. For providers of inpatient rehabilitation programs, the change with the greatest public awareness has been the increased focus on the “75% Rule,” which has been modified in regulation to have a 60% threshold; that is, 60% of the patients admitted to an inpatient rehabilitation program must have a diagnosis that is included in a list identified in regulation. In addition to having the diagnosis identified, the medical record must support that the beneficiary has received treatment for the identified diagnosis. If the threshold is not maintained on an annual basis, the organization stands the risk of losing their Medicare rehabilitation provider status. However, although the enforcement of the By Jane Snecinski, FACHE 75% Rule has placed an increased focus on the diagnoses of the patients admitted to inpatient rehabilitation programs, the work of the demonstration Recovery Audit Contractors (RACs) has the potential to have a staggering significant and immediate financial impact on any provider of inpatient rehabilitation programs/services. The focus of these audits, primarily, has been on “medical necessity,” as defined by federal regulation, guidelines, and the Conditions of Participation for inpatient rehabilitation. Moreover, even though medical necessity is a long-standing cornerstone of health care, the review of medical necessity is relatively new to the rehab market. This issue, it appears, is even more important than a diagnosis that is identified as compliant with the 75% Rule, because if the admission to inpatient rehabilitation is not deemed medically necessary, then the admission is denied—even if the patient has a “compliant” diagnosis. As addressed in Section 306 of the Medicare Prescription Drug Improvement and Modernization Act of 2003, the RAC demonstration project began in 2005 in Florida, California, and New York. The RACs have several objectives, but they are incentivized to recoup reimbursement for the Medicare program through denials of reimbursement for services. Inpatient rehabilitation was a primary focus of the RAC efforts in the demonstration states, including California and Florida. Although the plan was for CMS to expand the RAC program to all states within an established timeline, they have accelerated their implementation plan, due to the perceived success of the program. It is anticipated that the RAC program will be instituted in all states by 2009 (slightly delayed from the original plan). The mission of the RAC demonstration project (announced January 11, 2005) was to “reduce Medicare improper payments through the efficient detection and collection of overpayments and underpayments and the implementation of actions that will prevent future improper payments.” 1 Because the range of providers that receive Medicare payment is so broad, post acute providers, specifically providers of inpatient and outpatient rehabilitation, were reviewed by the RACs within the scope of their contract. As with all Medicare providers, improper payments in the post acute settings can be received for three primary reasons: n Services are provided and payment received for services that have not been deemed as ‘medically necessary’ for the level of care in which they were provided; n Codes/scores are submitted that result in payment that may not be completely correct or accurate, (e.g., inaccurate diagnostic coding, inaccurate coding of functional status, coding of diagnoses without documentation of treatment); and n The medical record/documentation does not ‘tell the story’ and provide enough support for the claim for which payment has been received. The understanding of these issues and integration into the documentation of inpatient rehabilitation, as well as proactive auditing and associated corrective actions, will be critical to surviving under the permanent RAC program. Continued on page 22 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org 21 March 2009
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