Maximizing Medicare: Understanding the Medicare Revenue Enhancement Program

1. Maximizing Medicare: Understanding the Medicare Revenue Enhancement Program 2011 Age and Disabilities Odyssey “Building a Quality Future” Presented by: Rose Kline, RN, BA, CPC, RAC-Ct Senior Project Consultant Department of Human Services State of MN Medicare Revenue Enhancement ProgramMREP

2. Objectives Participants will be able to: • Understand the role of the Medicare Revenue Enhancement Program (MREP) • List the 5 Medicare skilled service areas • Recognize the basic requirements of Medicare documentation • Understand the appeal process • Learn about available resources

3. MREP • What is MREP? • Why do we need it?

4. MREP Process Begins with you – The skilled nursing facilities

5. MREP • How will I know when to submit information to MREP?

6. MREP Denial Referral Packet The MREP Denial Referral Packet is your resource for the denial process.

7. MREP MREP determines if the Denial Referral Packet is: • Fee-for-Service Medicare (FFS) or • Medicare Advantage (dual eligible recipient)

8. MREP MREP will diligently review each Medicare claim for dual eligible clients to determine when a Medicare decision should be appealed.

9. MREP Determination of review is based on SNF Medicare Part A benefits for both the “Technical” and “Clinical Coverage” criteria.

10. Terms to Understand • 3-day Qualifying Hospital Stay • Benefit Period • 30-day Transfer Period

11. Coverage Criteria • Medicare Part A Entitlement • 3-day Qualifying Hospital Stay • Transferred to SNF within 30 days at a skilled level of care • Benefits days available • Care related to Qualifying Hospital Stay

12. MREP Medicare Part A Technical Eligibility Requirements

13. MREP Level of Care Requirements: • Skilled services • Coverage criteria: medically reasonable and necessary • Certification by MD

14. MREP Five Categories of Medicare coverage: • Direct Skilled Services • Teaching and Training • Rehab Services • Observation and Assessment • Skilled Management of a Treatment Plan

15. MREP • Direct Skilled Services Hands-on services e.g.: • IMs • IVs • Tube feeding (51% cal or 26% of daily cal with 501 ccs fluid/day) • Dressing changes with prescription ointments and aseptic technique

16. Skilled Services Defined Skilled nursing &/or skilled rehabilitation services are those services furnished pursuant to physician orders that: • Requires the skill of qualified technical or professional health care personnel, and • Must be provided directly by or under the general supervision of these skilled professionals to assure the safety of the patient and to achieve the medically desired result

17. Determining Whether a Service is Skilled • Inherent complexity • The intermediary considers the nature of the service and the skills required for safe and effective delivery of that service in deciding whether a service is a skilled service. Service must be must be reasonable & necessary to the treatment of the beneficiary’s condition. Skilled Nursing is 7 days/week & Rehab 5/wk.

18. MREP • Teaching and Training Teaching and training activities which require skilled nursing or rehabilitation personnel to teach a patient how to manage his treatment regimen.

19. Teaching & Training Activities • Teaching: • Self-administration of injectable medications or a complex range of medications • A newly diagnosed diabetic to administer insulin injections, prepare and follow a diabetic diet, and observe foot-care precautions. • Proper care of any specialized dressings or skin treatments • Gait training/teaching prosthesis care for a patient who has had a recent leg amputation • Teaching how to : • Care for a recent colostomy or ileostomy • Perform self-catheterization • Care for and maintain central venous lines • Use and care for braces, splints & esthetics and associated skincare

20. MREP • Rehabilitation Services: Physical Therapy Occupational Therapy Speech Therapy

21. MREP • Observation and Assessment Observation and assessment are skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s treatment regimen is essentially stabilized.

22. Reasonable Probability • Reasonable probability means that a potential complication or further acute episode was a likely possibility.

23. MREP • Management & Evaluation of a Patient Care Plan or Skilled Management of a Treatment Plan Condition + Age + Immobility = high potential for complications Skilled services may be needed to manage care, depending on the patient’s condition. This does not say that ALL patients require skilled management, or that if it is needed at first, the need continues indefinitely. Use your judgment to decide which patients do need skilled management and for how long.

24. Example of Management and Evaluation of a Patient Care Plan • An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestions, is confined to bed as a result of his debilitated conditions. To decrease the chest congestion, the physician has prescribed request changes in position, coughing, and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient’s immobility and confusion represent complicating factors which, when coupled with the chest congestion, could create high probability of a relapse. In this situation, skilled overseeing of the nonskilled services would be reasonable and necessary, pending the elimination of the chest congestion, to assure the patient’s medical safety.

25. MREP The Key: DOCUMENTATION DOCUMENTATION DOCUMENTATION TO SUPPORT THE SERVICES BEING PROVIDED

26. DocumentationWhy do we document? • The first and foremost reason is reimbursement • What services did the patient receive? • Are we going to be compensated for the care provided? • Other reasons: • Accreditation • Patients’ response to treatment • Nurses’ standards of practice • Legal concerns When health care professionals practice, there is an expectation of a certain level of care that will be provided. Failure to provide this acceptable standard of care can result in negligence.

27. MREP Documentation to Support Coverage There must be evidence of instability or the probability of a change in the patient’s condition. • Change in the care plan • Clinical flow sheets to suggest observation and assessment • Change in condition • Modifications in the plan of care

28. MREP Next Step: The Appeal

29. MREP What is the recipient’s coverage? • Fee-for-Service (FFS)/Medicare – Noridian (NAS) • Medicare Advantage (MA)/MSHO – Managed Care Organization (MCO) or payer

30. MREP Medicare • Demand Bill • Redetermination • Reconsideration • Administrative Law Judge (ALJ) Hearing ( https://www.noridianmedicare.com) NAS communicates with the SNF

31. MREP Medicare Advantage / MSHO • NO demand bill • Informal redetermination (I will communicate status to SNF) • MAXIMUS Federal Services

32. MREP Based on the outcome of the appeal if enhanced payment is received the remittance advices must be faxed to DHS: Attn: MREP/ Rose Fax: 651-431-7431

33. MREP You may contact me at: MN Department of Human Services Benefit Recovery Section/MREP Rose Kline, RN P.O. Box 64995 540 Cedar St. St. Paul, MN 55164-0995 651-431-3151 FAX: 651-431-7431 rosemary.kline@state.mn.us

34. More Information/Trainings Visit the MHCP Partners and Providers Homepage at www.dhs.state.mn.us/providers Enter in Search Field: Keyword “MREP”

35. MREP Homepage • MREP Process details • Quarterly Newsletters • Monthly MREP Sessions • Schedule • Training Handouts • PowerPoint Presentations • Webinar Instructions • State/Federal Resources

36. Communications • Provider E-mail Lists • Free e-mail subscription to MHCP News and Provider Information • Nursing Facilities • Therapies • Medical Equipment & Supplies

37. Thank you for attending! Questions?