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Regulatory MonitoringArchive for August, 2008
Editor’s note: The following are some numbers, facts and other important information about Medicare’s Recovery Audit Contractor (RAC) program:
Show the government the money: The RACs corrected more than $1 billion of Medicare improper payments from 2005 through March 27, 2008. Roughly 96% of the improper payments ($992.7 million) were overpayments collected from providers, while the remaining 4% ($37.8 million) were underpayments repaid to providers.
Inpatient is No. 1: Of the overpayments, 85% were collected from inpatient hospital providers, 6% from inpatient rehabilitation facilities, and 4% from outpatient hospital providers.
No contest: Providers chose to appeal only 14% of the RAC decisions. Of all the RAC overpayment determinations, only 4.6% were overturned on appeal. However, a memo from the California Hospital Association obtained by HCPro, Inc. says "the appeals data is incomplete, and significantly understates the volume and impact of provider appeal activity. The current report does not include appeals at the first level of appeal or other appeals in process with providers."
MSP flaws: $12.7 million was returned to the government through overpayments on Medicare Secondary Payer (MSP) RACs.
Appeal payback: Under the demonstration project, the RAC only needed to pay back the contingency fee if the claim was overturned at the first level. However, under the permanent RAC, the payback of the contingency fee would be at all levels.
Helpful Web sites: http://www.cms.hhs.gov/RAC; and www.aha.org/aha/issues/RAC
Sources: William Malm, ND, RN, president of Health Revenue Integrity Services, Inc.; CMS
The Government Accountability Office plans to begin a review of the Medicare RAC program near the end of this year, a spokesman for the department says.
John D. Dingell, D-MI, chairman of the Committee on Energy and Commerce, wrote a letter to the Government Accountability Office July 11 requesting it review the RAC program because of “numerous reports of problems with the implementation of the program.”
Laura A. Kopelson, GAO public affairs officer, said the GAO has accepted the request and plans to begin work on it in about four months. "At this time, there is no specified completion date," she writes in an e-mail to HCPro.
Earlier this year, CMS touted its RAC demonstration project for collecting more than $1.03 billion in Medicare improper payments – $980 million in claim RACs, and $12.7 million in Medicare Secondary Payer (MSP) RACs.
But it is not a perfect system, members of Congress say. Dingell’s letter cited the following problems:
• IRFs complaints. Inpatient rehabilitation facilities (IRFs) in California reported “inconsistent communication, the use of unqualified personnel by the contractor, and review practices inconsistent with Medicare policies.”
• Contingency fee abuse. The demonstration project allowed the RAC to keep its contingency fee so long as it survived the first level of appeal. It did not matter what happened at the ensuing levels.
• Wrong overturns. CMS contracted AdvanceMed to review findings in the pilot states. It found 40 percent of the denied IRF claims were wrong.
CMS did make corrections based on these findings. It stopped reviews of California IRFs; returned the contingency fee if the RAC finding was overturned at any level; ensured incentives are equal to collect overpayments and underpayments; and improved communication.
However, Congress still wants a review, according to Dingell’s letter, which was endorsed by four other members of Congress.
To read the letter in its entirety, click here.
Collecting that co-payment at the front lines can be a challenge for both staff members and patients. Debra Keller, admissions/registration director for the Grand Itasca Clinic and Hospital in Grand Rapids, MN, and advisory board member for the Patient Access Resource Center, offers the following tips:
- Use scripting as a vital tool toward getting that initial step started.
- Have signage so patients are aware that co-pays will be collected at the time of registration.
- During scheduling, tell patients that if they have their co-pay ready when they check in, their registration time will be shorter. When scheduling, tell patients for their convenience and to speed their registration process that they please have their co-pay ready when they check in.
- Have your staff members keep a co-pay spreadsheet at their desk where they can note the amounts they collect and amounts they do not collect.
- Have staff members turn in their spreadsheets to you at the end of each week. Tally their efforts and share the report with the whole group. Seeing their efforts both individually and as a whole will give them the incentive to see the collection column grow and non-collection column decrease. You may want to set a target goal for co-pays collected and offer an incentive.
- Consistency in the application of the facility standards as they relate to individuals presenting to the facility for treatment
- Initiation and utilization of a compliant system regarding any potential violations of EMTALA
- Most important, knowledge of the EMTALA requirements and training of staff to enable compliance in this complex area
This tip was adapted from A Practical Guide to EMTALA Compliance
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