2012 patient access goals

As we have nearly begun the second half of 2012, we’d like to give you and your staff the opportunity to talk about your goals and visions in patient access for the rest of this year.

Survive a recent audit? Handle a crisis effectively and efficiently?

We’d love to hear about it – and so would your colleagues. Send your thoughts to Associate Editor James Carroll at jcarroll@hcpro.com. And you could be featured on our Patient Access Resource Center blog or perhaps in this e-newsletter.

Good luck and have a great rest of the year!

Recovery auditor hot topics: Audit MICs struggling to identify overpayments

On March 20, the Office of Inspector General (OIG) issued a report that presents an early assessment of the efforts of Audit Medicaid Integrity Contractors (Audit MICs) to identify overpayments in Medicaid. Contained within the report are drastic figures that convey the fact that Audit MICs are having a difficult time identifying overpayments in their audits.

Only 11% of the study-assigned audits were completed with findings of $6.9 million in overpayments, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, states, and CMS, according to the report. This leaves 81% of audits that the MICs were unable to or unlikely to identify any underpayments or overpayments. The OIG suggests that problems with the data used and analysis conducted by Review MICs and CMS to identify audit targets led to this performance.

Another possible reason for this lack of success in finding overpayments is the lack of an overarching governing body over the Medicaid auditing landscape, suggests William Malm, ND, RN, CMAS, senior data projects manager at Craneware, Inc., based in Edinburgh, Scotland with a US office in Atlanta.

“States are having difficulty auditing on the Medicaid side due to the diversity and complexity of the regulations, and the lack of billing specifics in the individual state guidelines,” he says. “These business practices have not been well documented and there is no defensible source authority to proclaim that something is an overpayment or an underpayment.”

Continue reading.

OIG posts new compliance reviews, CMS issues press release on home health agency patient surveys, and more

On April 16, the OIG issued a Medicare compliance review of Georgetown University Hospital for years 2009 and 2010. The review found that 134 of the 265 claims reviewed resulted in overpayments totaling $659,000. View the OIG report. View the OIG report. OIG issues Medicare compliance review of Florida hospital On April 16, the OIG issued a Medicare compliance review of Bay Medical Center (Panama City, Fla.) for years 2009 and 2010. The review found that 48 of the 197 claims reviewed resulted in overpayments totaling $290,000. View the OIG report.

CMS issues minor edits to ABN instructions form

View the updated instructions.

CMS issues IPPS proposed rule for FY2013

Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes. In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) Program and proposes new policies and measures for the Hospital Value-Based Purchasing (VBP) Program. “It's good that they're lowering the burden on hospitals from tracking so many quality issues, but they're coming up with a couple other things, like [hospital-acquired conditions (HAC)],” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. “If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present on admission] POA indicators as well as the over-documentation issues that could lead to financial penalties,” Gold says. CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals. Read the full story on HCPro.com

Recent Recovery Auditor activity

DCS Healthcare added a new semi-automated issue for inpatient rehabilitation facility claims to its CMS-approved list for providers in New Hampshire, Massachusetts, Maine, Vermont, and Rhode Island.

HHS issues Affordable Insurance Exchanges final rule

On March 27, HHS issued a final rule in the Federal Register that implements the new Affordable Insurance Exchanges, consistent with the Affordable Care Act. The Exchanges will provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options on the basis of price, quality, and other factors. View the final rule

CMS to resolve incorrect claims processing issue for 12X and 13X bill types

On February 24, CMS sent out an update informing providers that it has identified a Medicare claims processing issue that has been causing hospital outpatient services rendered in an institutional setting to be processed incorrectly. Specifically, the notice provided guidance on claims inappropriately overlapping when billed with a 12X or 13X type of bill with the same date of service.

CMS had previously issued guidance in Transmittal R2386CP, which clarified that providers could separately bill outpatient services rendered prior to a non-covered inpatient admission. It also states that the dividing line for services billed on the inpatient and outpatient claims is the inpatient order, and that services “prior to the point of admission” are to be billed as outpatient services with a 13X bill type. This includes services in the outpatient and emergency departments.

But many providers continued to see denied inpatient cases involving 13X bill types, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.

CMS requires the creation of improper payment edits

In early March, CMS released two related transmittals that rescinded prior transmittals. These rescinded transmittals summarize issues that the Recovery Auditors have identified as causing significant overpayments. CMS is requiring the implementation of edits to either correct or prevent these errors.

One Time Notification Transmittal 1051, which is effective July 1, 2012, will require the development of edits to correct improper payments for the following areas:

Continue reading.

Three-day payment window explained

Join HCPro on Tuesday, April 17, at 1 p.m. (Eastern) for the 90-minute live audio   conference, Mastering the Three-Day Payment Window. During this program our expert speaker, Kimberly Anderwood Hoy will provide a brief history of the rule, breakdown its new additions,  and explain to providers how to correctly apply these changes at your   facility in 2012.

For more information or to order, call 800/650-6787and mention Source Code EZINEAD or visit the HCMarketplace.