Are you prepared for an unannounced Medicare visit?  As you know, a site visit is always scheduled during the re-enrollment period with documentation requested and pictures taken by the inspector.  Anecdotal evidence from all regions of the country indicates that Medicare contractors are performing inspections that are not based on re-enrollment.  If you haven’t already seen Medicare, there is a high degree of probability they WILL be at your front door soon.

The inspection covers about six pages of questions. Sample forms and licenses are requested.

This is what was asked, witnessed or requested:

ASKED:

1) Are you Accredited and for how long?

2) How many locations do you have?

3) Can you tell me the areas of service you cover?

4) What is your title?

5) What is your core business?

6) What is your ethnic population mix?

7) How do you handle the non-english speaking census? (The suggested answer is: either with translators on staff or access to your local university language department, if there was no one in the family or friends that could translate, which normally there is.)

If you provide oxygen:

8a) What qualifications do your personnel have for the oxygen equipment?

8b) Do you have contract or full time respiratory therapists?

A step-by-step process of what to collect, what to do with it once you’ve collected it, and how to present that data.

By Vianna Zimbel, BS, RT

860-657-9530 vzimbel@aol.com

Do you have brain cramp when it comes to Performance Improvement?  Most companies are good at collecting customer satisfaction surveys, but fail at everything else associated with this important and required process.

First- Remember that Performance Improvement is DATA DRIVEN, meaning it isn’t a hunch that your company is doing a pretty good job, or notes from a managers meeting. Performance Improvement is numbers. You can prove it. It isn’t where staff discuss “problems with AR”, it is unexpected denials by code and dollar amount.

Second- Medicare dictates a core list of topics for which your company must collect data:

1. customer satisfaction surveys




1. minimum questions (you can add more questions if you wish) are:




1. timeliness of service


2. response to concerns or complaints


3. the impact of your company’s business practices on the customer’s access to products & services (did they get what they need?)






2. adverse events (also known as incidents)




1. if you had none, state that fact.


2. If you had incidents in the past quarter, state that fact in your report and review for trends (your driver’s traffic accidents? Missed/late deliveries that caused a patient hospitalization for lack of the equipment? A particular product not functioning or malfunctioning?) What company process was changed in response to that incident? Who was responsible for making the change? When did the change occur and when do you expect results from that change?




3. complaints




1. define a ‘complaint’ (usually if the beneficiary demands to talk with a supervisor or manager) and then track TYPE of complaints as well as TIMELINESS of responding to complaints according to Medicare’s Quality Standards that require responding, in writing, within 14 calendar days of the complaint.




1. Collect complaints and then state the number in your PI report and review for trends.


2. How many complaints were responded within the 14 day guideline?




1. What company process was changed in response to the complaint(s)? What process can be changed to ensure beneficiaries get a written response within 14 days? Who is responsible for the change? When will the change occur and when do you expect results from that change?








4. Billing & Coding Errors




1. Medicare now requires that you trend billing & coding errors. They do not dictate anything beyond that. If you subscribe to RemitData you are already compliant, but otherwise, run a report of ‘unexpected’ denials and decide whether you want to present the information by total dollars denied, or how often that the code pops up compared to total number of claims billed.

Those are the basics for Medicare Compliance.

Accreditation organizations ask for additional data collection, such as:

1. Patient Files




1. Most accreditation organizations also require you to review customer records for ‘completeness and accuracy’. YOU decide what you want to audit in these files. You will need to create an audit checklist, pull files and review.  You probably want to use this opportunity to make sure problematic documents are completed. Be prepared for post-payment audits by internally policing documents that support claims for reimbursement: look for signed delivery tickets, date of delivery/date item billed, verifying you have the document for which you are using the ‘KX’ modifier. Remember that since this must be data driven, you’ve got to use that checklist you created for file audits to eventually create a summary figure: number of files audited divided by number that are compliant = a percentage.




2. You’ve got to look at something that is ‘high risk and/or high volume’ for your business.  It could be maintaining oxygen concentrators according to manufacturers guidelines (total concentrators out on rent vs. total number that have been PM’d within your defined timeframes).  It could be Customer education and documentation that it was provided for the equipment or supply provided.


3. Some accreditation organizations have their own unique set of additional topics they want you to collect data on.

Now comes the step most homecare companies don’t do very well: crunching the data numbers into percentages or pie charts or frequency of occurrences; and having a group meet on a quarterly basis to review those numbers.

Someone needs to identified as the group secretary who will take notes about whether and if the findings are below acceptable levels, a clear action plan with who is responsible for the activity, when it is going to occur, and what the expected changes will be as a result of the activity. Each topic should be spelled out in the report.  Next quarter, review the results with a second go-round of audits.  Did the planned action result in an improvement as anticipated, or does an alternative action need to be proposed because the earlier plan did not result in an improvement?