The New RAC HDMS. Featuring Sharon Briggman, of the SERT PGI LOGO*

Transcription

1 The New RAC HDMS Featuring Sharon Briggman, of the SERT PGI LOGO*

2 Welcome HDMS Users This presentation is intended to be your source for everything related to the renewed RAC Audit Program! Sharon Briggman from the Prometheus Group will give us the scoop on: Program changes Provider Portal tips Lisa Anderson will be providing some RAC Management tricks in HDMS at the end!

3 About the Speaker Sharon brings over 28 years of experience in the health insurance field including over 19 years of Medicare contractor experience in all areas of provider education and training. Prior to Prometheus, Sharon worked for Palmetto GBA in the capacity of Senior Ombudsman under Part A Home Health & Hospice and Part B Durable Medical Equipment (DME). In her capacity as an Ombudsman, Sharon worked to resolve and educate providers on critical issues referred by the anti-fraud unit, various internal departments, and congressional offices, including working with Federal prosecutors on fraud cases as an expert witness. Sharon serves as a member of the Region D DAC Committee, DME MACs Region C and D POE AG and Jurisdiction C Council. She also speaks regularly at National Industry Conferences in addition to Software User Conferences. Additional industry experience includes Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) currently a managed care system and renamed TRICARE, Blue Cross Blue Shield Major Medical and Medicaid. Sharon earned a bachelor s degree in Psychology from North Carolina Central University (NCCU).

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11 A Closer Look at the Discussion Period The Discussion Period request form is posted on the Performant Recovery website. Fill out the form and include the reason that you would like to discuss the case. There must be one Discussion form submitted per claim (no bundling claims on one form due to scanning processes). Attach supporting documentation for reconsideration. Indicate on the form if a physician-to-physician review is requested. If so, you will receive a call from the Discussion team to schedule the conference. Mail or fax the form to Performant. Acknowledgment of the Discussion request occurs when the form is scanned into the Performant system. This acknowledgement is viewable via your provider portal login. 11

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15 Audit Review May return medical record requests via: Mail: Paper or CD/DVD Documentation should be mailed to: Performant Recovery, Inc. Records department 2751 Southwest Boulevard San Angelo, TX If mailing documents, it is strongly recommended all medical records be sent to via a traceable carrier such as FedEx, UPS, DHL, registered USPS mail, in a tamper-proof, padded package. Fax: electronic submission of Medical Records (esmd) Please contact Performant if you are able to send medical records via esmd to make arrangements. 15

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20 Issue Details

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24 Portal Information The provider's overall ADR limit ADR letter mailed date Medical documentation received date Medical review completed date The outcome of the review (overpayment, underpayment, no finding) Discussion period information Appeals outcomes Case closure date Update Contact Info Note: The portal is updated nightly! 24

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26 Coping with RAC Audits in HDMS Collection & Denial Management can keep track of your RAC Audits for you! Mark a claim requested for RAC Audit with a special status code Use Templates to create a Worksheet to work those claims as often as you want! Change the status code and set for follow up to keep track of discussion time periods

27 Tracking RAC Requests in HDMS In Claim Maintenance: Mark your requests with a status like RAC request received and enter Follow Up Date: Today s date as soon as you receive them!

28 Tracking RAC Requests in HDMS In Worksheet Admin: Create a Template for RAC Audits TO DO and let HDMS create a Worksheet for you based on the Status Code! You will never forget a request again!

29 Tracking Submitted RAC Requests In Worksheet Admin: Create an additional template based on follow up date and your secondary RAC Status Code. HDMS will automatically remember those claims for you!

30 Thank you for joining us! Want to set up Collections & Denial Management to handle your RAC Audits? Contact: Lisa Anderson (248) x 334 We love Sharon! Contact: Sharon Briggman sharonb@prometheusteam.com or Amy Lawson amyl@prometheusteam.com

31 Important Reminder Regarding the ABN! The ABN, Form CMS R131 has been updated! The effective date for use of this ABN form is 6/21/2017. Providers should take note of the newly incorporated expiration date on the form (Exp. 03/2020). Background: March 2017: The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. While there are no changes to the form itself, providers should take note of the newly incorporated expiration date on the form (Exp. 03/2020). In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.

32 Important Tips! Submitting Medical Records Requested documentation may be submitted via: esmd Postal Mail Either images on CD/DVD or on paper Electronic Submission of Medical Documentation (esmd) Performant preferred method The esmd system allows providers and HIHs to electronically send their responses to Additional Documentation Request (ADR) letters to review contractors during the claims review process. One of the benefits of using esmd is that it can help mitigate late submissions and potential technical denials. Performant cannot recommend a HIH, however there are several HIH's available to offer esmd gateway services to Providers. More information is available at this CMS.gov link. It includes list of HIH vendors and how to contact them.

33 Important Tips! Submitting Medical Records Medical Record Submission via CD/DVD or Paper: If submitting via paper or CD/DVD a copy of the Bar Code Sheet(s) must be affixed to the requested documentation. Bundle documents for each claim separately to enable us to confirm receipt of documents.

34 Important Tips! Submitting Medical Records Medical Record Submission 1. In the example to the right there are 3 distinct record requests. Copy the Bar Code Sheet(s) as the first page for each corresponding set of documents. 2. Place a check mark where indicated to associate the claim # with the corresponding set of documents (the records for each claim should be a separate and distinct bundle). 3. Documentation submitted without the barcode identifier will be rejected. 18

35 Important Tips! Submitting Medical Records Include a copy of the Bar Code Sheet(s) with CD/DVD package Multiple charts can be sent on one CD/DVD but each chart request must be a separate PDF/TIFF file and named appropriately. Naming Convention for each claim submitted is: NPI#-Claim# Example: Claim number is NPI is File name is Scanned image resolution must be clear & legible dpi and in black and white Image format must be in either PDF or TIFF format (PDF is preferred ) For PDF format, DO NOT password protect the INDIVIDUAL PDF files. Instead, zip all PDFs into a WinZip file and encrypt it. CD/DVDs do not require encryption but it is recommended for security purposes. If encryption/password protection is desired, the following common WinZip options are accepted: Zip 2.0 compatible encryption 256-Bit AES encryption If a password is required to open a zipped CD/DVD please submit that password to Performant Recovery, prior to shipment, via the method below. password to: info@performantrac.com must include letter request id and claim number for identification.

36 Medical Record Submission via Paper: Include a copy of the Bar Code Request Sheet(s) Use standard 8 ½ x 11 paper 3 hole punched paper will NOT be accepted No staples or staples holes Important Tips! Submitting Medical Records Each chart should be individually secured with a rubber band or paper clip Photocopy must be of good quality and legible Records must be copied on only one side Pages should be top faced and face up Example: Bar Code Request Sheet