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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.”
OIG posts new compliance reviews, CMS issues press release on home health agency patient surveys, and more
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 ruleThree-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.
Regulations: CMS publishes EHR proposed rule, HHS publishes HIT standards
CMS publishes EHR Incentive Program—Stage 2 proposed rule
On March 7, CMS published the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs Stage 2 requirements proposed rule in the Federal Register. The Medicare and Medicaid EHR Incentive Programs will consist of three different stages of meaningful use requirements, with each stage requiring increasing use of EHRs and electronic information exchange.
HHS publishes health information technology standards
On March 7, The U.S. Department of Health and Human Services (HHS) proposed new and revised certification criteria would establish the technical capabilities and specify the related standards and implementation specifications that Certified Electronic Health Record (EHR) Technology would need to include to, at a minimum, support the achievement of meaningful use by eligible professionals, eligible hospitals, and critical access hospitals under the Medicare and Medicaid EHR Incentive Programs.
CMS publishes patient privacy guidance
On March 2, CMS published a certification letter that contains guidance concerning HIPAA standards. The letter specifically addresses permitted incidental uses and disclosures and includes reasonable safeguards that must be in place to ensure patient privacy.New! Revenue Cycle Institute releases 2011 Recovery Auditor Benchmarking Report
The Revenue Cycle Institute has released a new white paper, “2011 Recovery Auditor Benchmarking Report,” by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.
Q&A with Debbie Mackaman: Recovery auditors and more
1. What type of impact do you think the newly announced demonstration project for recovery auditor prepayment review will have on providers?The actual impact won’t be seen until later this year since CMS had delayed this project and then recently announced that it is expected to begin on or after June 1, 2012.
In theory, it could reduce the number of appeals that providers would have to file when they disagreed with the recovery auditors’ (RAs) findings.
However at this time there are several things that remain unclear – what the focus areas will be, what the volume of claims may be or what the process will be if the provider disagrees with the findings of the prepayment review.
CMS’ intent is to “lower the error rate by preventing improper payments rather than the traditional pay and chase methods” with their focus primarily being on claims that have historically resulted in high rates of improper payments.
Comparing the recovery auditor program (RAP) prepayment to current prepayment reviews under the MAC or CERT, providers will be looking at a delay in payment during the review process and hospitals from the 11 states that will be participating in the demonstration project should begin to consider the ramifications.
CMS has not indicated that certain hospitals will be included or excluded so prospective payment system (PPS) hospitals and critical access hospitals (CAH) should monitor the roll out of this project. Continue reading.
Overweight physicians display bias in obesity care
Cheryl Clark, for HealthLeaders Media
Doctors who are overweight or obese are less likely than physicians of normal weight to diagnose weight problems with their heavy patients or to launch discussions with them about their need to slim down, says a Johns Hopkins report that its authors say is the first of its kind.
The report “indicates that if you’re a heavier physician you are biased when it comes to providing obesity care and that may be something physicians do not realize they’re doing,” lead author Sara Bleich, assistant professor of health policy at Johns Hopkins Bloomberg School of Public Health, explains in an interview.
“When they see patients who look like themselves—in that overweight or obese category—they think, ‘This person looks like me and I feel healthy, therefore let me focus on the more extreme’” complaints or issues they may have, such as diabetes and hypertension, rather than the underlying excess weight which may exacerbate their health problems.
Bleich’s paper was published in this month’s issue of the journal Obesity.
The paper is based on responses to 49 questions in a cross-sectional survey answered by 500 randomly selected primary care physicians—internists and general and family practitioners—who see patients at least 35 hours a week. They were drawn from the Epocrates Honors Panel of 145,000 doctors verified by the American Medical Association’s master file, and they received a $25 voucher for their time.
Read more on HealthLeaders Media.
New! Revenue Cycle Institute releases 2011 Physician Supervision White Paper
The Revenue Cycle Institute has released a new white paper, “Physician Supervision: Analyzing Current Status and What to Expect in the Future,” by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.
To download the white paper, click here. Additional white papers can be accessed by clicking here.