Archive for November, 2008
Q: One of the challenges that many providers have faced is the inability to sufficiently interface (e.g., to see a human, get a return phone call, or otherwise interact in a personalized manner) with a RAC with respect to questions, concerns or confusion that occasionally arise. Will the permanent RACs be more welcoming of human interaction?
A: Yes. When you contact the RAC, they are required to return a phone call within one business day. In the permanent program, if a provider calls during the second period—or at any time—to discuss a determination, the RAC is required to let the provider speak to the medical director or the person that reviewed the claim.
Editor’s note: This Q&A was adapted from the November 13 RAC Open Door Forum. A CMS representative answered this question.
The permanent RAC program may be on hold for a short time. However, this doesn’t mean you should stop preparing for RACs. Using the 100 days to review and study the Office of Inspector General (OIG) reports and work plans is one way to internally identify like behaviors that may put you at risk for a RAC audit, suggests William L Malm, ND, partner at Health Revenue Integrity Services in Westlake, OH. The OIG has clearly outlined much of what the RACs are looking for in them, he notes.
So while you have this brief reprieve, get your facility in line by studying the OIG publications, Malm says. Taking the time to read and understand them can help you avoid recoupments.
Editor’s note: To view the latest OIG Work Plan, click here. To see a list of OIG reports, click here.
Improper payments for Medicare fee-for-service (FFS) decreased from 3.9% to 3.6% in fiscal year (FY) 2007, CMS announced in a November 17 press release. The change represents approximately $400 million.
For the first time CMS also reported Medicare Advantage improper payment rates for calendar year 2006 and national composite error rates for Medicaid and for the State Children’s Health Insurance Program (SCHIP) for 2007. CMS made $6.8 billion (or 10.6%) in improper payments for Medicare Advantage during calendar year 2006. The Medicaid composite error rate is 10.5% ($32.7 billion, the federal share being $18.6 billion). The SCHIP composite error rate is 14.7% ($1.2 billion, the federal share being $0.8 billion).
The improper payments do not necessarily reflect fraud, according to the press release. Incorrect coding or medically unnecessary procedures account for many of the improper payments. Inadequate documentation is a common problem leading to Medicaid and SCHIP improper payments.
CMS’ has gone to great efforts to reduce payment errors; the Medicare FFS error rate has declined more than 10% since 1996, according to the press release.
"We are using the most effective information-gathering tools available to help us identify and eliminate improper payments in our efforts to protect the integrity of CMS programs," Kerry Weems, CMS acting administrator said in the press release.
It looks like healthcare providers can count on the RAC medical record request limitations announced October 30—at least for now.
CMS reserves the right to review the request limits, but currently has no plan or set timeline as to when an adjustment may occur, CMS representative Lt. Terrence Lew, said during the November 13 RAC Open Door Forum.
“We could conceivably adjust the limits annually. But beyond that, we haven’t really set a schedule for adjusting them,” Lew said.
Lew also confirmed that CMS has spoken to the American Hospital Association as well as the American Medical Association regarding the medical record request limit.
For more information on the medical request limits, click here.
CMS has released a MLN Matters article related to changes in the deductible, coinsurance and premium rates for 2009.
To view the article, click here.
On November 7, the OIG issued a report on disproportionate share hospital (DSH) capital payments for the period October 1, 2000, through September 30, 2006. The OIG found that a number of rural hospitals and hospitals with fewer than 100 beds claimed DSH capital payments during this period, even though those facilities were, according to federal requirements, ineligible for these payments.
To read the report, click here.
President-elect Barack Obama has selected former Senator Tom Daschle to head the Health and Human Services Department, a move many say is the first step toward a universal healthcare model for Americans, according to a Novermber 20 article in the Wall Street Journal.
In addition, Montana Senator Max Baucus, chairman of the finance committee, which oversees taxes and about 50% of government spending, released a healthcare model similar to that proposed by Obama during his presidential campaign.
To read the story in the Wall Street Journal, click here.
Revenue cycle managers must continue to prepare their staff members to help confused patients with the Medicare Part D coverage gap.
More than 60% of patients who took a Medco Health Solutions survey do not fully understand the gap that forces patients to pay the entire cost of their prescription drugs, the Associated Press reports. And nearly 30% do not understand it at all, the survey says.
To read the full story in the Associated Press, click here.
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