Currently CMS has 280 Diagnostic Related Groups (DRGs) subject to the Post-Acute Care Transfer Policy. For many providers, the Post-Acute Care Transfer Policy affects more than 50% of their discharges. Under the Medicare Post Acute Transfer rule, acute care providers are paid less than the full DRG payment for many claims when the patient is transferred to either a post-acute facility or home health upon discharge. In some cases, the care plan is not followed as expected and the transferring hospital may be entitled to the full DRG payment.
Medicare is currently recouping overpayments related to this regulatory change. However, Medicare is not identifying the errors resulting in under-reimbursed claims. While CMS instructs Medicare contractors to edit transfer claims for potential overpayments, edits for underpayments do not exist. Without a lot of manual effort and review of the Medicare Common Working File, acute care providers have no way to identify those transfer claims for which they have been underpaid.
Per 42 CFR 412.4, when a patient is transferred to one of the following:
(1)To a hospital or distinct part hospital unit excluded from the prospective payment system described in subparts A through M of this part under subpart B of this part.
(2) To a skilled nursing facility.
(3) To home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge.
and his or her length of stay is less than the geometric mean length of stay for the MS-DRG to which the case is assigned, the transferring hospital is generally paid based on a graduated per diem rate for each day of stay, not to exceed the full MS-DRG payment that would have been made if the patient had been discharged without being transferred.
The per diem rate paid to a transferring hospital is calculated by dividing the full DRG payment by the geometric mean length of stay for the MS-DRG. Also, the policy generally provides for payment that is double the per diem amount for the first day, with each subsequent day paid at the per diem amount up to the full MS-DRG payment.
Also review regs (FR Vol 76 N0. 160 – August 18, 2011) for special payment methodology for specific DRGs and rules.
Approach to review
1. Client provides data from client
a. The most recent twelve months (from DOS) of data to be reviewed.
b. Continuing review should be to receive 6 months worth of data moving forward
c. Traditional Medicare inpatient discharges with end dates from 01/01/18/-12/31/18 for example
2. Sort data and identify all accounts containing a post acute DRG
3. Isolate all accounts with a post acute discharge status code.
4. Determine if length of stay for each account is less than Geometric mean for the coded DRG
5. Review the CWF for each claim of interest in the Medicare FISS system to record Hospital and SNF days used and HIQA and HIQH Date information
6. Complete queries and determine potential adjustments
7. Create list of accounts that need the name of post acute provider
8. Contact post-acute providers to determine if post-acute services received after hospital discharge & send confirmation letter to providers for determination
9. Review responses and determine additional claims recommended for adjustment.
Claim Approvals and Adjustments
1. After initial review all automatic 06(Home Health) adjustments will be sent for client review within 2 weeks of receiving data
2. Included on the list is original payment, original discharge status code, revised payment, revised discharge status code and additional revenue expected
3. Upon receipt of written approval, this service will access the individual accounts in the Medicare on-line system and manually adjust the claim
4. Claim will be monitored until adjudication
5. This process will be followed for any additional claims we determine should be recommended for adjustment
Status Reports and Meetings
1. Initial status report should be delivered within 2-3 days of data load
2. Initial 06 claims recommended for adjustment and status report #2 should be delivered within 2 weeks of data load. Included with this report should also be a listing of all the claims that require a post acute provider name.
3. Set up conference call to discuss findings and next steps at this point
4. Status report #3 should be released after initial claim have paid and faxes have been sent to post acute providers – (Is helpful if this status report goes out prior to client receiving initial invoice)
5. At this point monthly status reports will be sent to keep client informed
6. Also claim adjustment lists should be sent as faxes are received from providers and the claim is determined it should be adjusted .
7. A final report will be done for each period of data received (typically receive a year or in 6 month increments)
We will provide a “Proof of Concept” on a limited number of files to help your facility determine the need for this product. Proof of Concept can even include files that were previously reviewed by other contractors.
ICD-10 coding can have a significant impact on hospitals and other healthcare organizations’ bottomline. Through our ICD-10 services, we review where you may be leaving revenue on the table.
We draw from proprietary analytics and more than 30 years of coding expertise to conduct in-depth review of your ICD-10 coding and determine where processes could be improved or streamlined. Our I-10 Check solution differs from other coding evaluations in a number of ways
Identifying Key Risks
Most coding audits rely on random samples or 100 percent reviews of a specific diagnostic-related groups (DRGs) or a clinical family of DRGs. With our proprietary data analytics, we are able to sift through thousands of cases to focus on those accounts that have a statistically likely risk for under- or over-coding. These cases could represent compliance issues or revenue shortfalls.
Our approach enables us to perform a pinpoint review of your hospital’s ICD-10 performance. Certified ICD-10 experts will save you valuable time and resources by focusing on what statistically may be at risk, broken or unable to be fixed.
The services we provide are designed to complement your hospital’s existing CDI program, ICD-10 task force or internal audit initiatives; it is not designed to replace them. Our product’s statistically driven identification of coding, compliance and revenue issues allows you to clearly evaluate progress on these initiatives. By using this service, you will be able to monitor improvement in your ICD-10 coding and correct the inevitable coding erosion that follows such large-scale changes. The product identifies potential issues before they escalate into more substantial problems
Finally, as with all of our data-driven improvement products, we then work with you to make sure any issues get fixed and stay fixed through continual monitoring and education.
By utilizing this service, you will be able to answer in a quantitative manner – that is both measurable and defendable – the three critical questions senior management and your auditors will ask about your hospital’s ICD-10 coding:
How accurate is our coding? We examine your data to identify specific records that could be at risk for over- or under-coding. Then, our experts review these charts to ensure optimal coding accuracy for the at-risk records. We provide detailed reporting of its findings and works with your health information management staff to correct issues.
Is our reimbursement what it should be? We not only identifies potential reimbursement issues, but also allow you to re-bill those cases within the permissible payment windows, ensuring that your reimbursement is complete and accurate.
How is our coding compliance? Our reviews your coding data eliminate potential compliance issues. Our process provides for the review of specific cases at risk and allows for the training and education of your staff on corrections going forward. In addition, the data analytics employed by this service, allows you to monitor improvement over time so that once something is fixed it stays fixed. health and medical drg reviews
DRG Validation Audit
HIMpartners provides both onsite and remote DRG Validation Audits. Our auditors have years of experience and clients are able to review and interview our Auditors before assignment.
• DRG Validation identifies opportunities to establish accurate reimbursement.
• We review existing coding and documentation and run pre-bill or post bill
• Our experts also review medical records to document evidence for DRG shifts
• All suggested changes are available for client review for confirmation of changes.
• We provide education to staff to address the reason for changes which reduces future error.