Training Programs
Audits & Assessments
Regulatory MonitoringArchive for October, 2008
OIG issues review of high-dollar payments for inpatient and outpatient claims processed by Riverbend Government Benefits Administrator for calendar years (CY) 2004 and 2005
On October 16, the OIG issued a report on high-dollar payments for inpatient and outpatient claims processed by Riverbend Government Benefits Administrator, a Medicare fiscal intermediary, for CYs 2004 and 2005. The OIG recommended that Riverbend recover overpayments totaling $4.9 million for 49 inpatient high-dollar claims and 51 outpatient high-dollar claims.
View the OIG report.
CMS issues final decision memo for percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting
On October 14, CMS issued a final decision memo in which it made no changes to the national coverage determination for PTA of the carotid artery concurrent with stenting.
View the final decision memo.
CMS implements quarterly update to interest rate for Medicare overpayments and underpayments
On October 15, CMS issued a transmittal instructing Medicare contractors to implement an interest rate of 11.375% for Medicare overpayments and underpayments.
Effective date: October 22, 2008
Implementation date: October 22, 2008
View the transmittal.
CMS clarifies previous transmittal on the national coverage determination (NCD) for continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA)
On October 15, CMS issued a transmittal clarifying a previous transmittal regarding the NCD for CPAP therapy for OSA.
Effective date: March 13, 2008
Implementation date: August 4, 2008
View the transmittal.
Hospitals in New York, Connecticut, and New Jersey are increasingly finding themselves providing uncompensated care to poor, uninsured, and sometimes illegal, immigrants.
These hospitals face a dilemma because they feel it is their ethical obligation to provide care to those who show up at their door, according to The New York Times, but some hospitals report losing up to $10 million a year caring for these types of patients.
Medicaid covers illegal immigrants in emergency situations, but other conditions, which may be debilitating but are not emergencies, are not covered.
Hospital officials say that providing care at the time the patient presents to the hospital, even if it’s not an emergency situation, can save the hospital money by dealing with the health issue before it becomes urgent. In addition, community education about available healthcare resources can prevent patients from coming to the hospital if they are aware of other options.
Sources: HealthLeaders Media, The New York Times
Effective November 1, hospitals must have a plan in place to detect, mitigate, and prevent red flags that signal potential identity theft, according to the Identity Theft Red Flags and Address Discrepancies Under the Fair and Accurate Credit Transactions Act of 2003 (final rule).
There was confusion over whether the rule, which is primarily geared toward financial institutions and other lenders, also applied to healthcare providers. However, although the rule doesn’t specifically reference hospitals, it does imply that they may fit the legislation’s extremely broad definition of “creditor” because they permit a deferred payment of certain ongoing accounts.
Essentially, providers become “creditors” when they establish payment plan. Supplementary information published with the rule states the following: Creditors in the healthcare field may be at risk of medical identity theft (i.e., identity theft for the purpose of obtaining medical services) and, therefore, must identify red flags that reflect this risk.
Examples of red flags could include, but are not limited to, any of the following:
- A mismatch between an individual’s address according to his insurance policy and what appears on his driver’s license
- A photograph on a driver’s license or other ID that doesn’t match the individual presenting it
- An address provided that is a P.O. box or mail drop
- The telephone number provided is for a pager or answering service
To view the red flag rule, which was published in the November 9, 2007 Federal Register, visit this government Web site. For illustrative examples that hospitals can use when developing an identity theft prevention program, refer to Supplement A to Appendix J of the rule. Also refer to the World Privacy Forum Web site to view its latest report titled “Red Flag and Address Discrepancy Requirements: Suggestions for Health Care Providers,” released September 24.
Click here to view the report.
Now that you know which RAC will come to your facility, it’s time to prepare for some changes. CMS revamped the program after the three-year demonstration project, and providers can expect to see the changes reflected in the nationwide permanent program.
Chief among them are:
RAC medical director.
Demonstration RACs: Not required
Permanent RACs: Mandatory
Coding experts.
Demonstration RACs: Optional
Permanent RACs: Mandatory
Credentials of reviewers provided upon request.
Demonstration RACs: Not required
Permanent RACs: Mandatory
Discussion with CMD regarding claim denials if requested.
Demonstration RACs: Not required
Permanent RACs: Mandatory
AC validation process.
Demonstration RACs: Optional
Permanent RACs: Limited
External validation process.
Demonstration RACs: Not required
Permanent RACs: Mandatory
RAC must pay back the contingency fee if the claim is overturned on appeal.
Demonstration RACs: Only required if claim is overturned on the first level of appeals
Permanent RACs: Required if claim is overturned at all levels of appeals
Maximum look back date.
Demonstration RACs: None
Permanent RACs: October 1, 2007
RACs allowed to review claims in current fiscal year.
Demonstration RACs: No
Permanent RACs: Yes
RACs solely for MSP.
Demonstration RACs: Yes
Permanent RACs: No
RAC claim status Web page.
Demonstration RACs: Not required
Permanent RACs: By January 2010
Limits on number of medical records requested.
Demonstration RACs: Optional. Each RACs set own limit
Permanent RACs: Mandatory. CMS will establish uniform limits.
Editor’s note: For more differences in the permanent program, see the next edition of The RAC Report October 30, 2008.
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