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CMS Supplemental Medical Review Contractor Audits Texas Providers

(February 6, 2014): Strategic Health Solutions (Strategic) is a Supplemental Medical Review Contractor and is the latest CMS program integrity contractor to stampede into the Lone Star State.  Strategic is an Omaha, Nebraska-based company that provides professional health care education and audit services for both federal and state government agencies.  In recent months, a wide range of Texas providers – in particular, home health agencies – are starting to receive audit letters asking for supporting documentation associated with Medicare Parts A and B claims billed in connection with a specific patient and date of service.  In such instances, the postpayment audits conducted have focused on home health face-to-face encounters.  Accompanying letters sent with the contractor’s request have typically noted the underlying deficiencies that the Department of Health and Human Services Office of Inspector General (OIG) has found with face-to-face documentation prior to home health certification.  The purpose of this article is to discuss the various audits now being handled by Strategic Health Solutions and to discuss ways that a provider can reduce his / her level of risk and the avoid being subjected to a post-payment audit.

I.            Overview of Work Performed by Strategic Health Solutions: 

Strategic was awarded multiple contracts by the Centers for Medicare and Medicaid Services (CMS).  Areas worked by Strategic include:

Supplemental Medical Review Contractor.

Medicare Outreach and Quality Assurance.

 Part D Formulary and Benefits Review Contractor.

 Medicare Secondary Payor Integration Contractor.

Risk Adjustment Data Validation / Intake Medical Review Contractor.

 Medicare Part C and Part D Program Integrity Technical Assistance.

Education Medicaid Integrity Contract (Education MIC) Task Order 1.

 Education Medicaid Integrity Contract (Education MIC) Task Order 2.

Quality of Care Monitor.

Specialty Medical Review of Medicare Part A and B Claims.

Medicare Prescription Drug Benefit Part D Payment Process Support Services.

A quick review of the company’s activities shows that Strategic has been very active working with both the Medicare and Medicaid programs around the country. In recent years, the company has performed educational, quality assurance, specialty audit and general post-payment review services for federal and state government agencies.

II.            Strategic’s Work as a Supplemental Medical Review Contractor:

In 2012, Strategic Health Solutions was awarded a five-year contract by CMS to serve as a Supplemental Medical Review Contractor. In this capacity, Strategic has been tasked with performing post-payment audits of Medicare Part A, Medicare Part B, and Durable Medical Equipment (DME) claims submitted by health care providers and suppliers around the country.

The company’s aim is to lower the improper payments rates and increase efficiencies of the medical review functions of the Medicare and Medicaid programs. Strategic intends to evaluate medical records and other related documentation to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices. The company will be performing medical review in accordance with CMS regulations, CMS’ Program Integrity Manual, and other current and future CMS Provider Compliance Group / Division of Medical Review and Education initiatives. Importantly, the contractor has been employing statistical sampling and extrapolation practices, thereby significantly magnifying any projected overpayments identified through the contractor’s efforts.

III.            Face-to-Face Requirements for Home Health Certification:

Recently, Strategic’s supplemental audits conducted have included the examination of the face-to-face documentation requirements associated with home health care.

Effective April 1, 2011, the Patient Protection and Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare’s home health services. This mandate requires the certifying physician to document that he / she, or a certified non-physician practitioner working with the physician, has seen the patient. CMS implemented the face-to-face encounter requirement of the ACA through the Home Health Prospective Payment System (HHPPS) Calendar Year rulemaking. The Final Rule acknowledges that documentation of the face-to-face encounter must be present on certifications for patients with Starts of Care on / after January 1, 2011.

Notably, HHS-OIG work conducted prior to the ACA mandate found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home health care.  As a result, this finding constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.980(b). Based on this data, CMS has directed Strategic to perform post-payment reviews of Medicare Part A claims billed for home health services. Consequently, Strategic is requesting additional documentation from Texas home health providers for these claims for the Supplemental Medical Review of home health services authorized by CMS.

IV.            Steps You Can Take to Prepare for an Audit by Strategic Health Services:

From the outset, it is important to remember that the steps you need to take to reduce the likelihood of claims deficiencies are essentially the same as those you would employ to prepare for a post-payment audit of Medicare claims by a Zone Program Integrity Contractor (ZPIC) or other CMS program integrity contractor.  As Liles Parker has previously emphasized, after analyzing the various medical necessity, coverage, coding and billing requirements required for a claim to qualify for payment, our firm has identified “Seven Elements of a Payable Claim”.  Medicare Part A, Medicare Part B and DME claims can be comprehensively assessed using this tool.  Health care providers and suppliers – including Texas-based home health care agencies – should carefully analyze their practices to better ensure that all regulatory and statutory requirements which cover a particular claim have been met prior to billing Medicare for the services or supplies at issue.  An abbreviated overview of these seven elements includes:

Element #1:  Is the medical necessity of the services or claims properly documented?

Element #2: Were the services at issue actually provided?  

Element #3:  Even if medically necessary and provided, are the services “Tainted” due to a violation of law?

Element #4:  Do the services qualify for coverage under the payor’s coverage guidelines?

Element #5:  Is your documentation of the services at issue complete?

Element #6: Have you properly coded the services at issue?

Element #7: Did you properly bill the payor for the services rendered?

IV.   Final Remarks:

Each year, the level of scrutiny currently being levied on health care providers and suppliers has continued to increase.  The current post-payment audits of home health agencies in Texas being conducted by Strategic Health Solutions are merely the latest iteration of this trend.  As a participating provider or supplier in the Medicare program, you and your practice are obligated to comply with each and every regulatory / statutory requirement which applies to the specific services / supplies you are billing to the Medicare program.  If your practice is audited by Strategic Health Solutions, a ZPIC or another program integrity contractor, we recommend that you consult with a health lawyer experienced in responding to this and other post-payment reviews by a contractor (such as Strategic Health Solutions) working for CMS. Need help determining whether your claims are in compliance with Medicare statutes and other federal regulations? We would be more than happy to assist you.

Healthcare LawyerRobert W. Liles, Esq., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law.  Liles Parker attorneys represent health care providers and suppliers around the country in connection with Medicare audits by ZPICs and other CMS program integrity contractors.  The firm also represents health care providers in HIPAA Omnibus Rule risk assessments, privacy breach matters, State Medical Board inquiries and regulatory compliance reviews.  For a free consultation, call Robert at:  1 (800) 475-1906.

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