Training Programs
Audits & Assessments
Regulatory MonitoringArchive for July, 2009
Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on July 15.
CMS hopes to identify additional contractors within the next few days. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:
- Review provider actions to determine whether fraud, waste, or abuse may have occurred
- Audit provider claims
- Identify overpayments
- Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care
There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will provide education to providers and others on Medicaid payment integrity and quality of care.
CMS acknowledged on the call that it could do a better job of provider outreach, and it is taking measures to increase educational efforts, now that it has finished building the Medicaid Integrity Program organization and developing the audit process.
Fortunately, additional resources will soon become available for providers. CMS plans to soon release FAQs, a procurement timeline, background on the program and its goals, as well as other information on the Medicaid Integrity Program Web site. CMS also plans to release Web-based training currently in development for pharmacies.
Hospitals aren’t the only providers that need to prepare: 44% of the current audits focus on hospitals, but 29% are on long-term care facilities, 21% of audits are on pharmacies, and the remaining 6% are on physicians, labs, transportation, and other types of providers, according to CMS.
RACs vs. MICs
MICs have been termed “RACs for Medicaid,” but there are certainly differences between the programs. For example, the RAC lookback period is three years, but MICs base the length of time on individual state lookback guidelines. Similarly, the number of days a provider has to produce medical record copies for MICs is dependant on state rules, unlike with RACs, where providers have 45 days regardless of their location. In addition, MICs have no set medical request limits, while RACs max out at 200. Also, CMS will not reimburse providers for the cost of copying records, which is also different from the RAC program.
And unlike RACs, MICs are not paid by contingency fee, but rather through a sort of fee-for-service model. The dollars MICs recover aren’t tied to their compensation, according to CMS, although they will be eligible for bonuses based on how “effective and efficient” they are. Finally, in some cases MICs will do desk audits, and in other instances, auditors will come on-site to do the reviews.
MICs will also attempt to coordinate with RACs so as not to audit the same facilities simultaneously, CMS Medicaid Integrity Program field director Robb Miller said on the call.
Editor’s note: If you’ve undergone a MIC audit, we want to hear from you. Please e-mail Managing Editor Andrea Kraynak at akraynak@hcpro.com.
CMS will post an audio recording and transcript to the Special Open Door Forum Web site for 30 days beginning July 24. To contact CMS regarding the Medicaid Integrity Program or audits, e-mail CMS at Medicaid_integrity_program@cms.hhs.gov.
It seems that many providers still struggle to understand the RAC discussion period that CMS has helpfully given them-much less take advantage of it when the permanent program rolls out in their area.
The discussion period is new to the permanent program, though it is somewhat akin to the rebuttal period, which was part of the demonstration program. “The rebuttal period was used in the demonstration because it is part of the Medicare appeals process,” says Camille Cohen, MSW, MBA, CHC, compliance manager at 3M Health Information Systems in Salt Lake City.
But CMS found providers had a slightly different need from the rebuttal process during the demonstration project, she says. Originally designed to discuss mathematical errors, providers instead used the rebuttal period for all kinds of discussions. Hence, CMS decided to initiate the discussion period specifically for RACs.
“The RACs and CMS are trying to work with providers, and the discussion period is a huge open door for providers to have a dialogue with their RAC,” Cohen says.
Providers can use this chance to communicate with their RACs to discuss much more than math. Not only can they use it to try to change the RAC’s mind on a denial, but they can use it as a learning opportunity. A RAC may discuss how it came up with the determination. Providers should seek out that information so they don’t keep making the same mistakes, says Cohen.
That information may also be helpful during the appeals process, she says. “But the discussion period doesn’t lengthen in any way shape or form the appeals process and it doesn’t take the place of the appeals process,” she reminds us. “All it does is open up the dialogue with the RAC to hopefully take care of problems such as missing or incomplete documentation before you have to go through the appeal process.”
In addition, some RACs have indicated during outreach sessions that they will accept missing documentation. “CMS emphasized providers shouldn’t go create documentation, but if a provider has documentation, but it is missing from the information received by the RAC, some RACs will accept the missing documentation after the fact,” Cohen says. For example, if a physician discharge summary had been dictated, but never filed-the RAC would likely accept that during the discussion period, she says.
The discussion period has two different start times, depending on whether it is for an automated or complex review. With an automated review, the provider finds out there has been a review and a denial when it receives a demand letter from the RAC. Receipt of that letter kicks off the discussion period. But for complex reviews, the discussion period begins when the provider receives the review results letter, which would arrive prior to the demand letter, giving the provider additional time to discuss the denial with its RAC. The discussion period ends upon recoupment of the money (i.e., day 41) regardless of the type of review.
But providers shouldn’t wait until day 39 or 40 to contact their RAC. “CMS was very careful to say to providers that they should contact their RAC as soon as possible during the discussion period because it doesn’t stop the recoupment,” Cohen says. “But if the provider can quickly convince the RAC that an error was made in denying the claim during the discussion period, and the demand/remittance step isn’t initiated, there may be the opportunity to stop the process.”
To effectively and efficiently take advantage of the RAC discussion period, Cohen recommends providers do the following:
- Group similar denials whenever possible. Use your tracking database to group issues and then talk about them globally. “That way, when you talk to your RAC, instead of having 200 issues to discuss, you have 10. You’ll probably be a lot more successful.”
- Stay organized. Especially when it comes to complex reviews, organization is critical. Use tracking databases or spreadsheets to document and track denials. They will help you keep on top of deadlines and recognize commonalities between denials that may help identify whether a claim is defensible during the discussion period or appeals process, or when you need to correct an error.
- Use strategy. “You’ll only want to go to the RAC during the discussion period for those claims you really feel like you want to defend,” says Cohen. “I’d avoid calling them with 50 claims and asking the RAC to go through each one to explain why they denied it. I’m not sure you want to spend that much time, much less the RAC.”
- Don’t get sidetracked. Providers should use the discussion period, but shouldn’t let it distract them from determining whether they want to appeal the claim, or given the early deadlines they need to meet, if they want to stop recoupment (e.g., they can appeal by day 30). There are many decisions providers need to make, Cohen says. So it is important that they don’t let the discussion period distract them too much from everything else that needs to be done.
Editor’s note: We would like to take a moment to welcome Camille Cohen, MSW, MBA, CHC, compliance manager at 3M Health Information Systems in Salt Lake City, to the RAC Report Advisory Board.
CMS is often asked about other claim types that may be affected by a full inpatient denial and if the RACs will deny other claim types associated with the inpatient stay, such as physician evaluation and management services. At this time the RAC will not automatically deny claims that are associated with a full inpatient denial. However, these claims may be reviewed individually and there may be a need to fully/partially adjust the claim based on the documentation submitted.
- Marketing its medical devices to treat atrial fibrillation (the most common cardiac arrhythmia or abnormal heart rhythm), a use that is not approved by the FDA
- Promoting expensive heart surgeries using the company’s devices when less invasive alternatives were appropriate
- Advising hospitals to up-code surgical procedures using the company’s devices to inflate Medicare reimbursements
- Paying kickbacks to healthcare providers to use its devices
OIG issues reports on oxaliplatin billing
On July 1, the OIG issued two reports on oxaliplatin billing at Kootenai Medical Center and University of California San Diego Medical Center. The OIG found that both organizations billed incorrectly for oxaliplatin and received overpayments.
OIG issues reports on payments for Epogen
On June 24, the OIG issued two audit reports on Epogen billing at Fresenius Medical Care-Wynnewood and Lancaster General Hospital Dialysis Center. The OIG found that both organizations received overpayments.
Join MedicareFind today for direct links to all the documents in our regulatory database.
CMS implements FDG PET NCD
On July 17, CMS issued two transmittals to implement its recent NCD for FDG PET for solid tumors and myeloma. CMS is adopting a coverage framework that replaces the four-part diagnosis, staging, restaging and monitoring response to treatment categories with a two-part framework that differentiates FDG PET imaging used to inform the initial antitumor treatment strategy from other uses related to guiding subsequent antitumor treatment strategies after the completion of initial treatment.
Effective date: April 6, 2009
Implementation date: August 17, 2009 for local edits; OCTOBER 5, 2009, for FISS and CWF edits
MLN Matters article
CMS released an MLN Matters article related to a transmittal previously outlined in Medicare Weekly Update: Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Join MedicareFind today for a direct link to this and all the documents in our regulatory database.
By Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.
In a May 12 post, clarification was given regarding a “non-patient” and reference laboratory testing. Continuing with this discussion, Critical access hospitals (CAH) also received good news in Transmittal 1729 to the Claims Processing Manual, dated May 8, 2009. Under Section 148 of MIPPA (Medicare Improvements for Patients and Providers Act), a CAH will be paid 101% of reasonable cost for outpatient clinical diagnostic laboratory tests for those patients who are not physically present in the CAH at the time the specimen is collected. These patients are referred to as “non-patients” since only a specimen is received for the date of service. Prior to this transmittal, all hospitals providing laboratory services to “non-patients” were instructed to bill on Type of Bill (TOB) 14X which triggered reimbursement under the Clinical Laboratory Fee Schedule.
To read more, click over to the MedicareMentor Blog.
In addition, Kimberly Anderwood Hoy, JD, CPC, regulatory specialist at HCPro, Inc., has posted a response regarding condition code 44 and observation services.
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine
