There are two main types of medical reviews, sometimes called “probes”: prepayment and postpayment. They mean exactly what their names imply. Contractors can request documentation after a claim is filed and before payment is made, or they can select claims for review after claims have been paid. As stated earlier, the Medicare program was built on a foundation of trust and doesn’t require documentation up front in order to receive payment. Since the advent of electronic claims filing, even less is required. Therefore, the MR system is in place to verify that providers are filing claims appropriately.
In 2013, several OIG studies and investigations found that SNFs had deficiencies in quality of care, did not develop appropriate care plans, and failed to provide adequate care to beneficiaries. In fiscal year 2012, Medicare paid $32.2 billion for SNF services. The reviewers determined the extent to which SNFs developed care plans that met Medicare requirements, provided services in accordance with care plans, and planned for beneficiaries’ discharges as required. Reviewers also identified examples of poor-quality care.
Q. When sharing patients’/residents’ functional outcomes with your managed care organization (MCO), should you share overall outcomes or only outcomes of the MCO’s patients?
A. When sharing patients’/residents’ functional outcomes with the MCO you want to keep everything focused on their members to the extent you’re able to. If your systems or other information aren’t able or sophisticated enough to be parsed out per plan, however, then at a minimum try to keep it to just managed care patients, because the service model for managed care patients is completely different from skilled nursing facility (SNF) Medicare patients.
Every spring, CMS makes available the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for SNFs. The agency offers variant reports for a number of other Part A provider types, including hospitals, home health agencies, and hospices. These tools, which provide comparative billing data across a handful of setting-specific risk areas, can play an important part in a provider’s corporate compliance and ethics program. To get the most out of the report, SNFs should have a strategy in place for integrating its findings into their corporate compliance and ethics program before accessing this year’s edition.
CMS has announced that they will mail the first group of the new Medicare cards to Medicare Eligible Beneficiaries beginning April 1, 2018. Due to the magnitude of this endeavor, CMS will be using a staggered rollout process. This means not all Medicare Eligible Beneficiaries will receive the New Medicare Card with this initial mailing. The time table for issuing New Medicare Cards is projected to last from April 1, 2018 through April 16, 2019. The mailings will not be advertised, will not follow a set geographical pattern or time frame, and there will be no special notifications sent to Providers of Medicare Services. This is all designed to prevent any theft of the cards for fraudulent purposes and to protect the Medicare Eligible Beneficiaries from Identity Theft.