July 26, 2011

New RAC PACT Continues to Raise Questions

By

gbryant100EDITOR’S NOTE: Understanding the bottom-line ramifications of the Centers for Medicare & Medicaid Services’ (CMS) post-acute transfer policy is challenging for many hospitals. Therefore, in response to the need to provide more clarity, RACmonitor recently sponsored a live Webinar with Gloryanne Bryant, RHIA, CCS, CCDS, the regional managing director of HIM for Kaiser’s 21 acute-care hospitals in northern California. Here is a recap of questions posed by participants and answered by Bryant.

 

RM:

 

Could you please provide a specific citation regarding the 60-day re-billing timeframe?

 

GB:

 

Section 6402(d) of PPACA amended the Social Security Act to require an entity to return any overpayments it receives and to notify the appropriate authorities. The overpayment must be reported and returned to the appropriate entity (such as CMS, OIG or the carrier) no later than 60 days from "the date on which the overpayment was identified" or "the date any corresponding cost report is due, if applicable," according to the language of the legislation. Furthermore, the PPACA makes the retention of an overpayment beyond this time frame an issue under the False Claims Act.

 

RM:

 

If a provider does not have access to the Common Working File (CWF), and the customer service representative refuses to disclose that information?

 

GB:

 

Contact the Manager or supervisor at your MAC/FI and explain to them who you are and why you need access. Ask for their information and email and send a written request to them. As a last resort you could contact the Regional CMS office as well and request assistance.

 

RM:

 

What is the correct discharge disposition for a patient who is discharged to home with palliative care provided by a hospice agency?

 

GB:

 

Home with palliative care is considered hospice, so use the discharge disposition code of 50 - Home with hospice care 51 - Transferred to hospice facility (i.e. Hospice bed in SNF) Not part of PACT rule. Note: IP Coding staff must validate and be sure that this status (discharge disposition) is accurate and correct the status if wrong.

 

RM:

 

Does all discharge documentation need to be in the medical record for a patient who never really received Home Health Care?

 

GB:

 

Traditionally, the medical record is our “source document” to validate the correct discharge disposition, but now the RACs are using the CWF as a source document. I recommend you talk to your hospital RAC Coordinator or Compliance Officer about setting up a process for situations such as this. You may need to establish a policy.

 

RM:

 

Do you find that HIM and Compliance have a good sense of the PACT rule?

 

GB:

I have found over the years that there is a general knowledge and awareness of PACT but the in-depth aspects of PACT payment methodology and the exceptions to the rule with condition codes is not as well known nor understood. This is certainly an area for greater education.

 

RM:

 

Have you had experience with an external vendor conducting PACT recoveries? and if so how did that go?

 

GB:

 

Yes I've had two different experiences with using an external vendor to be the PACT audit validation firm.  In both situations the vendor went into the CWF on behalf of my organization to help identify variations in the final discharge disposition as compared to that of the medical record or what HIM has coded. The outcome of the auditing and data mining was positive and rebillings were conducted and a summary report was produced.

 



 

RM:

 

What type of corrective action plan items would you recommend for RAC PACT errors?

 

GB:

 

Depending upon the findings, I would narrow down the issue or issues, i.e., documentation, post discharge CWF variations, HIM coding, Home Health and condition codes, etc.

 

Education is always a good choice to have as an action item. Also include ongoing auditing and validation process of the patient status.  If you have the ability to use an external vendor to conduct data mining that also might be a corrective action item. Include in your action plan, the individual responsible and a timeline for each action item. Also if data mining or auditing is an action item, request a summary report be provided at a minimum on a quarterly basis.

 

RM:

 

Thank you Gloryanne Bryant. We look forward to your next article and future Webinars.

 

To comment on this article please go to editor@racmonitor.com

 

This email address is being protected from spambots. You need JavaScript enabled to view it.