Indiana Medicaid Providers

On April 17, 2012, the Indiana Health Coverage Programs (“IHCP”) published a banner page to clarify billing and reimbursement for transportation of Medicaid recipients between hospitals.  In the event a Medicaid recipient is discharged from an inpatient stay at the original hospital and is transferred to another hospital, using transportation services, the provider transporting the patient may bill for the services and receive payment for the transportation if the provider is enrolled with the IHCP as a transportation provider.  

Payment for the transportation of a patient while still in inpatient status in not payable separate from the inpatient payment for the original inpatient hospital stay.  An example of such transportation, would be if while maintaining inpatient status with the original admitting hospital, the patient needs specialized services in another hospital.  In this case, the transportation is not a separately billable Medicaid transportation service.  The original admitting hospital should record the services obtained at the other hospital, including the transportation, in the appropriate ancillary cost center relating to the services obtained.  The original admitting hospital should not use revenue code 54X (Ambulance).  If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.

As required by §6411 of the Affordable Care Act (“ACA”), Medicaid RACs were to be up and running on January 1, 2012.  Although the Medicaid RACs are not quite there, 21 states selected a Medicaid RAC contractor as of March 20; and three states, New Jersey, South Carolina, and Indiana, have hospitals that have received requests for medical records from their new Medicaid RACs.  Due to CMS’ past experience with Medicare RACs, it is requiring some basic standards for Medicaid audits, including, Medicaid RACs must: hire a licensed doctor of medicine or osteopathy to act as the RAC’s medical director, hire certified coders, and accept electronic medical record submissions from providers and notify them of audit findings within 60 days.  The Medicaid RACs must operate a toll-free customer service phone line during normal business hours and each RAC must work with the state to develop an education and outreach program for providers.  RACs must also review fee-for-service claims, however it is up to the States to decide if Medicaid managed care will be reviewed.  States will decide whether to require Medicaid RACs to post their audit targets the way Medicare RACs do.  The States will decide how many medical records the RACs can request from providers and how often, whether RACs are permitted to do medical necessity reviews, whether RACs will extrapolate findings into larger overpayment determinations, and how to handle appeals.  The States will also report fraud to Medicaid fraud control units or other law enforcement.  There is a three-year look-back period for Medicaid RAC audits.

In a February 2012 presentation by HMS (Indiana’s Medicaid RAC) and Thomson Reuters it stated that Medicaid providers will be subject to Medicaid credit balance reviews, automated reviews and complex reviews and that the Indiana Medicaid agency will provide “final approval of the type of audits the RAC will deploy for each provider and/or audit project.”  It is not clear whether Indiana will require HMS to notify providers and suppliers of approved audit issues before launching the audits.

The government has high hopes for overpayment recovery from the Medicaid RACs as the Medicaid integrity contractor (“MIC”) audits have been a bust so far.  MICs audit Medicaid claims based on leads from “review MICs.”  Upon OIG review, 81% of the audits assigned to audit MICs did not identify overpayments or are unlikely to.  The OIGs reasoning for the low finding of overpayments is because Audit MICS were hindered, in part because audit targets were poorly identified and were often inappropriate, and in part because there were problems with the Medicaid Statistical Information System (“MSIS”) data used in MIC audits, which would sometimes send audit MICs on a wild goose chase.  Based on its finding, OIG is recommending more collaborative audits, better selection of audit targets and possibly the consolidation of review and audit MICs under one program integrity contractor.  If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.

A recent IHCP Newsletter published an article regarding the various requirements for disenrolling certain Medicaid enrollees.  When Indiana Health Coverage Program (“IHCP”) members transition to a long-term care facility, a psychiatric residential treatment facility (“PRTF”), hospice care, a waiver program, or to the 590 program; the member must be disenrolled from the Hoosier Healthwise risk-based managed care (“RBMC”) program.  Until Hoosier Healthwise disenrollment occurs, fee-for-services (“FFS”) claims, except for carved-out services, for these members will be denied.  

Long-Term Institutional Care

                The nursing facility or ICF/MR must request a Pre-Admission Screening Resident Review (“PASRR”) for facility placement before admission and notify the member’s managed care entity (“MCE”) of the PASRR request within 72 hours of admission. The State will then approve the PASRR request and designate the appropriate level of care in IndianaAIM, which will automatically trigger RBMC disenrollment and result in same-day processing for disenrollment and level of care. If the provider fails to verify an IHCP member’s coverage or fails to contact the MCE within 72 hours, the provider is responsible for charges incurred until the member is disenrolled from the MCE.  If the provider does not complete the paperwork for the appropriate level of care determination, and the member is still enrolled in Hoosier Healthwise after two months, the MCE is no longer liable for payment, and as long as the patient remains a member of the MCE, and FFS claims will be denied.  If the member’s PASRR is in processing while the member is linked to an MCE, the financial responsibility lies with the MCE for up to 60 days.  However, an MCE may obtain services for its members in a nursing facility for a short-term stay, less than 30 days, and the MCE may negotiate rates for reimbursing the nursing facilities for these short-term stays.

Psychiatric Residential Treatment Facility Services

                Before a PRTF can be reimbursed for FFS claims for a Hoosier Healthwise member, the member must be disenrolled from the MCE.  The PRTF must fax a PRTF prior authorization (“PA”) request to the PA vendor, ADVANTAGE Health Solutions, at 1-800-689-2759.    The PRTF must also contact the MCE before the member is admitted to the PRTF, or immediately upon admission, if advance notice is not feasible.   ADVANTAGE will approve the PA request, then enter the PRTF level of care in IndianaAIM which will automatically trigger RBMC disenrollment and provide for same day processing.  Upon discharge, the PRTF must notify ADVANTAGE, and ADVANTAGE will end-date the level of care for the member.  If the member is still eligible for RBMC, the auto-assignment process will immediately reassign the member to the member’s previous MCE, effective the first or 15^th of the month, depending on the disenrollment date.

Hospice Care

                Although hospice care is not covered under Hoosier Healthwise, terminally ill members may qualify for hospice care under the FFS Medicaid program upon disenrollment from RBMC.  Hospice providers must fax a hospice election form to ADVANTAGE at 1-800-689-2759 and contact the MCE the member is enrolled in.  ADVANTAGE will approve the request and designate the appropriate hospice level of care in IndianaAIM, which will automatically trigger RBMC disenrollment providing same day processing.  RBMC disenrollment documentation should be faxed to (317) 810-4488.  MCEs are required to coordinate care for its members who are transitioning into hospice and give the hospice provider any information necessary to complete the hospice election form.

Home and Community-Based Waiver Services

                Home and Community-Based Waiver Services (“HCBS”) are excluded from Hoosier Healthwise, and therefore members approved for waivers must be disenrolled from RBMC.  The MCE must coordinate care for a member during the member’s transition to HCBS, until disenrollment is effective.  The case manager must submit a Notice of Action to the Division of Disability and Rehabilitative Services (“DDRS”) for autism, developmental disabilities, and support services waivers; or the Division of Aging (“DA”) for aged and disabled, and traumatic brain injury waivers.  The appropriate division will review the waiver designation request and enter a waiver level of care into IndianaAIM, which will automatically disenroll the member from RBMC, effective the date the level of care was processed.  If a retroactive level of care date is entered, the disenrollment date will be the “processing date.”

Medicaid-to-590 Program Disenrollment

                Hoosier Healthwise members being transitioned to the 590 program must be disenrolled from RBMC.  As most members seeking enrollment in the 590 program are on disability Medicaid and not in Hoosier Healthwise, the facility must send a request to suspend Medicaid, to the county casework of the Division of Family Resources Service Center.   The facility must then fax State form 32696 E/D/T (Enrollment/Discharge/Transfer) to the HP Eligibility Unit at (317) 488-5217, to enroll the member in the 590 Program.   The HP Eligibility Unit will enter the enrollment and fax the completed for back to the facility, which will trigger RBMC disenrollment, effective the same day.   If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.

The Indiana Medicaid migration to International Classification of Diseases, Tenth Edition (ICD-10) remains unaltered as the Centers for Medicare & Medicaid Services (“CMS”) has not offered a set time line for the ICD-10 implementation.  Further information will be forthcoming, as soon as CMS provides definitive guidance regarding implementation dates.  If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.

Effective January 1, 2012, the Indiana Health Coverage Programs (“IHCP”) expanded the provider enrollment classifications to include comprehensive outpatient rehabilitation facilities (“CORFs”) and independent diagnostic testing facilities (“IDTFs”).  CORFs and IDTFs may enroll in the following IHCP programs: traditional Medicaid, Assistance to Residents in County Homes (“ARCH”), 590 Program, Hoosier Healthwise, and Care Select.  CORFs and IDTFs are enrolled under the moderate risk category and are subject to an application fee during enrollment or revalidation. 

A CORF is a facility primarily engaged in providing outpatient rehabilitation services to the injured or disabled, or patients recovering from illness with a plan of treatment under the supervision of a physician.  CORFs are required to provide outpatient mental health services (405 IAC 5-20-8), physical therapy and physician services; and may provide speech-language therapy and occupational therapy services.  CORFs should use provider type code “04-Rehabilitation Facility” and provider specialty code “041-Comprehensive Outpatient Rehabilitation Facility.”   The billing criteria states CORF services should be billed on a CMS-1500 Professional claim form or the Health Insurance Portability and Accountability Act (“HIPAA”) 837P transaction using place-of-service code 62-CORF. 

An IDTF is a diagnostic testing facility that is independent of a physician’s office or hospital and furnishes diagnostic tests but does not use test results to directly treat patients.  An IDTF can be differentiated from similar facilities by ownership structure and types of services provided.  Before enrolling in IHCP, an IDTF must be enrolled in Medicare where it will be required to provide a list of all the Current Procedural Terminology (CPT®1) and Healthcare Common Procedure Coding System (HCPCS) codes for the services to be performed as well as a list of equipment used to perform the tests.  In order to perform additional tests not on the original Medicare application, the IDTF will need to amend its Medicare application to add codes and equipment.  An IDTF must also employ at least one supervisory physician, not a physician group practice, who is proficient in the performance and interpretation of each type of diagnostic procedure performed by the IDTF.  IDTFs should use provider type code “28-Laboratory” and provider specialty code “282-Independent Diagnostic Testing Facility” or “283-Independent Diagnostic Testing Facility, Mobile.”  The billing criteria states IDTF services should be billed on a CMS-1500 Professional claim form or HIPPA 837P transaction using place-of-service code 81-Independent Laboratory.  If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.

The Indiana Office of Medicaid Policy and Planning (“OMPP”) contracted with Thomson Reuters Healthcare to provide an enhanced fraud and abuse detection system (“FADS”). As a part of FADS, Thomson Reuters has subcontracted HMS to provide independent recovery audit contractor (“RAC”) services in compliance with Section 6411 of the Patient Protection and Affordable Care Act of 2010. HMS will audit provider payments and related financial records to identify and recover or correct Medicaid payments that were overpaid or underpaid. HMS is initially identifying and auditing inpatient hospital providers with outstanding credit balances, and has begun notifying selected providers of upcoming audits. If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.

Section 6111 of the Health Care Reform Law, the Patient Protection and Affordable Care Act (PPACA), formed the basis for the establishment of a new Independent Informal Dispute Resolution (IIDR) process within the Civil Money Penalty scheme. Per Federal Nursing Home Regulations at 42 CFR 488.431, the new IIDR process has specific time lines and requirements for facilities to meet in order to take advantage IIDR. On October 14, 2011, CMS issued Survey & Certification Memorandum 12-02-NH that provides further guidance on the new IIDR process.

The new IIDR process is an option for facilities to elect if the facility is the subject of a Civil Money Penalty (CMP) that will be collected and placed in an escrow account. CMS is phasing in the CMS collection and escrow provisions of the PPACA and attendant regulations and will only be applying the CMP collection and escrow authority on the most serious deficiencies. Until further notice from CMS only those deficiencies that cite actual harm or immediate jeopardy (G or above) will be subject to the CMP collection and escrow and only those deficiencies will trigger the opportunity for IIDR. Any CMPs imposed for D, E and F deficiencies will be collected under the current process and are not subject to the new IIDR process.

Federal funding is available to States, through the State Survey Agency, for development of the IIDR process. The Indiana State Department of Health (ISDH) recently issued an alert indicating that the department is in the process of developing a new IIDR process according to the CMS guidance. The new IIDR process must:

1.       Offer a facility the opportunity for IIDR within 30 calendar days of notice of imposition of CMP that will be collected and placed into escrow. A facility has 10 calendar days to request IIDR after receiving notice.

2.       Be completed within 60 calendar days of receipt of the facility request for IIDR. “Completed” IIDR means that (a) a final decision has been rendered, (b) a written report has been generated, and (c) the ISDH has provided written notice to the facility of the decision.

3.       Generate a written record of the decision before the CMP is collected. Such written record must include (a) each disputed deficiency/survey finding, (b) a summary of the IIDR recommendation with rationale for the result, (c) documents submitted by the facility, and (d) comments submitted to the IIDR by the Ombudsman and/or residents and their representatives.

4.       Notify the Ombudsman, resident and resident’s representative of the opportunity to submit comments to the IIDR entity prior to the completion of the IIDR process.

5.       Be administered by an entity that does not have a conflict of interest with the ISDH (State Survey Agency) and that has specific understanding of Medicare and Medicaid program requirements.

CMS indicates that for States to receive Federal funds for IIDR in FY 2012, States must have a process and estimated budget submitted to CMS by November 30, 2011. Furthermore, the new IIDR process is set to begin on January 1, 2012. It is unclear at this time whether the ISDH will meet either deadline. Given that Indiana law regarding state agencies contracting for services requires a fairly lengthy procurement process, it does not seem likely that the ISDH process will be finalized and ready by January 1, 2012. For deficiencies that are subject to the new IIDR process, States may not charge facilities for the IIDR process. For situations that do not require the new IIDR (deficiencies that do not require escrowing of CMP), the State may develop and charge for its own resolution process.

On August 12^th, 2011, the Centers for Medicare and Medicaid Services (“CMS”) released an update to the June 17^th, 2011, Survey and Certification Memorandum 11-30-NH (the “Memorandum”) that provides guidance to State Survey Agencies (“SSA”), the Indiana State Department of Health (“ISDH”) in Indiana, regarding the reporting of reasonable suspicions of crimes in long term care facilities (“LTC”) (click here for the updated Memorandum: Updated S&C 11-30-NH).

The Memorandum was published due to the passage of the Elder Justice Act that, in part, requires certain covered individuals to report reasonable suspicions of crimes in that occur in LTCs to the ISDH and a local law enforcement agency.  The revised memorandum includes a Questions and Answers document, at pages 13-18, and guidance on the content of required notice regarding anti-retaliation provisions.

CMS Questions and Answers

The additional CMS guidance provides, unfortunately, only a few new pieces of information. For the most part the Questions and Answers regurgitate information that was already communicated in the original Memorandum. That being said, the following are new guidance from CMS:

·         Reporting a reasonable suspicion of a crime does not require “first-hand knowledge” of the events giving rise to the reasonable suspicion.

·         Continuing Care Retirement Communities must comply with the reporting requirements and, specifically, notices that are required to be posted must be so posted in the SNF/NF portion of the community and not in each building or unit of the entire community.

·         To promote a culture of safety, and to encourage reporting of reasonable suspicions of crimes, it is not recommended that facilities require covered individuals report to the facility when a report of a reasonable suspicion of a crime is made. Anti-retaliation provisions of the reporting requirement reinforce this premise.

o   However, this guidance must be balanced with the requirement for facilities to ensure that all alleged violations involving mistreatment, abuse, neglect, injuries of unknown origin and misappropriation of resident property are immediately reported to the administrator and other officials in accordance with current law.

·         The 2-hour and 24-hour reporting requirements for reports of reasonable suspicions of crimes (2-hours when events results in serious bodily injury, and 24-hours for all other reports) are based on actual (clock) time, and not business hours.

·         Incidents such as falls, bruising/injuries of unknown origin, resident-on-resident abuse, and other events, may be subject to the crimes reporting requirement, but are case specific. Each of these events would be reportable as an incident, but whether there is a reasonable suspicion of a crime depends on the surrounding circumstances.

Indiana State Department of Health Guidance

The ISDH is currently working on drafts of several documents including a general advisory letter regarding the entire reporting requirement, an implementation checklist and timeline, sample posters for notice requirements, and its own Questions and Answers document. The Indiana Health Care Association, as well as other long term care trade associations, are working with the ISDH in the development of these documents, which should be released within the month.

Recommendations

LTC facilities should immediately develop policies and procedures implementing the crimes reporting requirements. According to CMS, the law is in effect and should be enforced by State and Federal Surveyors.

Training of covered individuals (owners, operators, employees, managers, agents or contractors of the facility) regarding their individual duty under the requirement is critical. Each facility will want to be sure that each covered individual understands his/her responsibility, how to make a report, how to join a group report if a group report is being made, that the individual is are not to be retaliated against for making a report to the ISDH or local law enforcement and if retaliation occurs how the individual can make a report regarding such retaliation.

Long Term Nursing Homes need to reach out to their local law enforcement agency, either the county sheriff or city/town police, as applicable, regarding communication of reports. Establishing a relationship with local law enforcement for purposes of reporting reasonable suspicions and understanding what constitutes a crime in the local jurisdiction are key components to implementation.

If you have any questions about the crime reporting requirements, please contact Zach Cattell at 317-636-4341.

Questions remain frequent among long term care providers in Indiana regarding facility-level impacts of the decision by the Indiana Office of Medicaid Policy and Planning (“OMPP”) to eliminate reimbursement for bed-hold days.  The elimination of reimbursement for bed-holds was effective February 1, 2011 (For a copy of this bulletin, click here), and the Indiana Medicaid State Plan will be amended in the coming months to finalize elimination of reimbursement.  OMPP has also posted, and periodically updated, a news summary on www.IndianaMedicaid.com that discusses the impact of the reimbursement changes on Indiana’s long term care facilities and their residents (Click here for the news summary).

More recently, requirements for long term care facilities to maintain updated bed-hold policies were discussed during a panel presentation at the 2011 Indiana Health Care Association's ("IHCA") Convention & Expo in May.  In addition to the above OMPP-issued materials, the IHCA offers the following points for long term care facilities when developing bed-hold policies. 

·         Facilities must have a bed-hold policy that states whether or not the facility allows a resident to pay to hold a bed during a leave of absence

o    Though facilities are not required to allow a resident to pay to hold a bed, facilities must still have a policy that states whether or not payment for holding a bed is permitted by the facility

·         The duration of the bed-hold period must be clearly stated in the facility policy

·         Bed-hold policies should state that Indiana Medicaid does not reimburse for bed-holds

·         Payment by residents for bed-holds must follow applicable Medicare and Medicaid guidelines regarding billing for non-covered services

·         Charges for bed-holds should be set at fair market value and must be equally applied to all residents regardless of payor source

o    Facilities may be at risk for Anti-Kickback violations related to improper inducements to government program beneficiaries if charges for bed-holds are not fair market value and equal application of those charges are not maintained.  However, an exception to the Anti-Kickback statute may apply in certain circumstances for bed-hold charges that are unable to be collected.  This exception depends on certain elements regarding facility advertisements, other relevant services and financial need of the resident. 

·         If a resident on leave is expected to return to the facility, regardless of whether they have paid to hold a bed, the facility is not required to discharge the resident

·         If a resident is discharged from a facility, however, the facility must permit the resident to return to the first available semi-private bed when (i) the resident continues to qualify for Medicaid, (ii) the resident requires nursing-level care and (iii) the facility is able to provide appropriate care for the resident.

o    A resident may be discharged from the facility for many reasons including, but not limited to, the resident’s failure to pay for a bed-hold or when the bed-hold period expires.  Facilities must follow applicable regulations and procedures when discharging a resident.

If you have questions about this article or about bed hold policies, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 or Leigh Ann O'Neill at 317-238-6346.  .

On March 31, 2011, CMS released the long-awaited rules proposed to implement the provisions in PPACA, the Health Care Reform legislation enacted on March 23, 2010, referred to as the Affordable Care Act, on Accountable Care Organizations ("ACOs") and the Medicare Shared Savings Program that is designed to contract with these organizations. Likewise, the same day, the antitrust agencies, the Federal Trade Commission ("FTC") and the Antitrust Division of the Department of Justice ("DOJ"), issued proposed enforcement guidelines relating to the size, scope and ability of an ACO to contract in the commercial market and how that affects Medicare Shared Savings Program contracts as well. Additionally, the Centers for Medicare and Medicaid ("CMS") and the HHS Office of Inspector General ("OIG") proposed various waivers for standard Stark, Antikickback and Civil Money Penalty rules relating to ACO activities. Finally, the Internal Revenue Service ("IRS") issued a notice requesting comments on its existing private inurement and private benefit rules relating to tax-exempt entities and their financial relationships with "insiders".

• Home Health Services (5%)
• Hospital Inpatient and Outpatient Services (5%)
• Privately-Owned Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) (3%)
• Community Residential Facilities for Developmental Disabled (CRFs/DD)(3%)