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Regulatory MonitoringArchive for April, 2009
Are RACs violating CMS’ own rules? Palomar Medical Center in Escondido, CA believes they are.
CMS requires “good cause” for reopening and reviewing claims more than one year after payment, but RACs regularly reopened claims between one and four years old during the demonstration project without just cause.
Palomar is continuing its fight against this practice; it filed a complaint against HHS in U.S. District Court Southern District of California March 24.
Palomar’s fight began in 2007 when PRG-Schultz-the RAC for California during the demonstration project-denied a 2005 claim. Palomar appealed the denial to the Administrative Law Judge level. In October 2008, the ALJ decided in Palomar’s favor. The ALJ also found that PRG-Shultz “had not shown ‘good cause’ to reopen the claim more than one year after payment, as required by Medicare regulations,” according to the complaint Palomar filed in March. The ALJ also determined it had jurisdiction to determine whether the RAC properly reopened the claim.
However, the Medicare Appeals Counsel reversed the ALJ’s decision that the reopening was improper and “held that the ALJ lacked jurisdiction to determine whether the RAC had lawfully reopened the claim,” according to a February 13 letter to Palomar.
The complaint Palomar filed in March asserts the decision to overturn the ALJ ruling violates Palomar’s right to due process and that the RAC violated Medicare rules for reopening claims in effect during the demonstration project.
Per 42 CFR § 405.980(b)(1), a contractor can reopen a claim for any reason within one year of payment, however to open a claim between one and four years post-payment, contractors must have “good cause” to do so per 42 CFR § 405.980(b)(2).
This has been a long-standing concern-many healthcare organizations believe the RACs bent CMS’ own rules during the demonstration project.
The decision whether RACs can reopen claims more than one year after payment is important to many healthcare organizations with small operating margins.
The Revenue Cycle Institute is bringing its three biggest Medicare compliance educational offerings together in one huge event!
The “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors” will be held October 26-27, 2009, at the Westin Buckhead Atlanta.
The one and a-half day seminar is comprised of three hot button tracks that will provide solutions to today’s toughest regulatory challenges:
- The Recovery Audit Contractor program
- Observation status
- Physician advisors: Highly customized sessions for physician advisors to learn key aspects of Medicare compliance. New this year!
Attendees sign up for one track and get all three!
This one-of-a-kind seminar is designed to provide the most comprehensive and uniquely-tailored experience. The Medicare Compliance Forum provides three distinguished tracks:
- RAC Track: Defend your organization from RAC takebacks. This track will provide you with the critical strategies and helpful tools direct from professionals who have been through the demonstration project and are ready to take on the permanent program. No more boring overviews-Get something tangible you can take back to your organization. Get tried-and-true recommendations and valuable tools to help you and your team be prepared when RACs head your way.
- Observation Status Track: Know the rules of engagement. The challenge of properly classifying a patient as observation or inpatient affects both the clinical and financial success of a hospital. Our distinguished speakers hail from administrative, compliance, financial, and clinical backgrounds to bring you an exceptionally well-rounded program designed to help you master one-day stays and observation status.
- Physician Advisor Track: Understand the Medicare regulations that affect physician advisors. Physician Advisors and their organizations need to work together to reduce risk and protect revenue. This track features interactive sessions to educate physician advisors, VPMAs, and other professionals on RACs, observation status, pay for performance, and other important Medicare regulations. Attendees will also learn the skills and qualities and roles and responsibilities of an effective physician advisor.
Sign up for one track and you can pick and choose which sessions to attend from any of the tracks. Plus, attendees will receive all the materials to take back from every session, every track.
Click here to find out more about the 2009 Medicare Compliance Forum.
CMS has posted the recording, transcript and other related information from the April 8 RAC Open Door Forum for Part A providers to the CMS Web site.
The recording and transcript will be available for 30 days.
Revenue Cycle Institute releases new White Papers on Incident to and E/M auditing
The HCPro Revenue Cycle Institute has just released two new White Papers:
- “Incident To in Provider-Based Departments: Meet Medicare’s ordering, supervision, and follow-up requirements,” by Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
- “Evaluation and Management Auditing: Ensure appropriate coding and reimbursement for your practice,” by Joe Rivet, CPC, CCS-P, CEMC, CICA, regulatory specialist at HCPro, Inc, and instructor of HCPro’s new Evaluation and Management Boot Camp
To download the White Papers, visit the Revenue Cycle Institute Web site.
CMS has announced a new pilot program—called the Care Transitions Project—aimed at eliminating unnecessary hospital readmissions.
Fourteen communities have been selected to participate in the program. Each of the communities is led by a state Quality Improvement Organization (QIO). QIOs work throughout the country as part of CMS’ quality program to help healthcare providers, consumers, and stakeholder groups to refine care delivery systems to ensure Medicare patients receive high quality and high-value care.
The Colorado Foundation for Medical Care has created a map of the 14 community QIOs selected to participate in the project. CMS will monitor the success of the Care Transitions Project by monitoring the rates at which patients in these communities return to the hospital. The project will run until summer 2011.
Sources: Care Transitions QIOSC
2. What policies are in place to recoup losses after a default, and if so please provide copies?
3. What enhanced authorities does CMS require to protect the program?
By Kimberly Hoy, regulatory specialist for HCPro
This was an especially light week for items from CMS for hospitals. This is, perhaps, because shortly we should see the FY2010 Inpatient Prospective Payment System Proposed Rule.
I did want to discuss a new FAQ on Medically Unlikely Edits (MUEs) that brings up some questions. The new FAQ focuses on Advanced Beneficiary Notices (ABNs), pointing out that a beneficiary can not be billed for units in excess of an MUE even if the provider issues an ABN to the beneficiary. CMS explains that an MUE denial is a coding denial, and that ABN provisions only apply to medical necessity denials.
However, CMS also recently updated FAQ 8736 related to reporting medically necessary units in excess of an MUE. They discussed the use of several modifiers to report medically necessary excess units on separately lines. This implies that there are excess units that are medically necessary and other instances where the excess units are not medically necessary. The excess units provided, but judged as not medically necessary, would presumably not be reportable with the indicated modifiers and would be subject to the MUEs. The reason they fail the edit then, seems to be a lack of medical necessity rather than a coding error. This seems to indicate that perhaps there are some services in excess of MUEs that are legitimately provided, but not medically necessary; however, CMS has categorized them as “coding denials.”
I do want to caution providers that, normally, denials that are outside of the ABN provisions result in the service then being billable to the patient without an ABN, as they are only protected from liability for services within the ABN provisions. However, CMS has previously stated in Program Integrity Manual Transmittal 178 that excess units may not be billed to the patients. Further, CMS stated in that same transmittal, as well as in FAQ 8737, that there is no appeal process for these MUEs. This is the only time I am aware of that the hospital can not be paid by anyone, under any circumstances, for services they legitimately provided.
CMS has provided two contacts for giving feedback and making inquiries about the MUEs. If a provider wants to request a change to the value of an MUE, they would do so through National Correct Coding Initiative, Correct Coding Solutions, LLC, P.O. Box 907, Carmel, IN, 46082-0907. The fax number is 317/571-1745. For general inquiries, they have provided the following contact at CMS in FAQ 8741: valeria.allen@cms.hhs.gov.
The next CMS Hospital & Hospital Quality Open Door Forum conference call has been postponed until May 6 at 2 p.m. Eastern time. To access the call, dial 800/837-1935 and reference 89323669 as the conference ID.
CMS will also allow access to the "encore" (i.e., recorded) playback of this call beginning two hours after the live conference call has ended. It will expire after three business days. To listen to the encore playback, dial 800/642-1687 and enter 89323669 as the conference ID.
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