Revenue Cycle Institute » Managed care

Number of uninsured increases by 700,000 in 2008

Case Management Weekly — Wed, 08 Jul 2009 15:05:00 +0000

Based on the Centers for Disease Control and Prevention’s (CDC) National Health Interview Survey, 43.8 million Americans did not have health insurance in 2008. That’s 700,000 more people than in 2007 and 2.8 million more than 1997.

The amount of children under 18 that were uninsured in 2008 remained the same as in 2007 at 8.9%, and was down from 1997 at 13.9%.

Massachusetts had the lowest rate of uninsured persons (3%), and Texas had the highest (22.9%).

Source: Centers for Disease Control and Prevention

Healthcare fraud effects public and private insurance alike

Compliance Monitor — Wed, 08 Jul 2009 04:00:00 +0000

A report published by the George Washington University Medical Center, Health Insurance Fraud: An Overview, states that the healthcare fraud problem is not specific to public insurers (i.e., Medicare and Medicaid). According to the report’s authors, Sara Rosenbaum, Nancy Lopez, and Scott Stifler, private insurance providers are just as susceptible to fraud as Medicare and Medicaid.

The report states, “What is absolutely clear from virtually every reliable source on the subject is that healthcare fraud is a systemic problem affecting public and private insurers alike, in the individual market, the employer-sponsored group market, and public programs.”

The report also states that medical providers commit 80% of healthcare fraud, consumers commit 10%, and a combination of insurers and their employees commit the final 10%.

The report’s authors argue the reason Medicare and Medicaid appear to be more susceptible to fraud and abuse is because those programs cover the elderly, women, minorities, the less educated, and the poor, who are also the most vulnerable to fraud.

RACs and Medicare Advantage

The RAC Report — Thu, 28 May 2009 04:00:00 +0000

Q: Are the Medicare Advantage plans included in RAC audits?

A: According to Section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Medicare Advantage plans are not included in RAC audits. They are exempt from the RAC program, as the RAC is focusing on Part A & Part B providers.

According to the RAC Status Document FY 2006:

Section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (see Appendix A) directs the Secretary of the U.S. Department of Health and Human Services (HHS) to demonstrate the use of Recovery Audit Contractors (RAC) in:

1) Identifying Medicare underpayments and overpayments; and

2) Recouping Medicare overpayments.

Under the demonstration, the Centers for Medicare & Medicaid Services (CMS) pays the RACs on a contingency basis; that is, the RACs receive a portion of what they identify and collect. The demonstration program is designed to determine whether the use of RACs will be a cost effective means of adding resources to ensure correct payments are being made to Medicare providers and to ensure that taxpayer funds are used for their intended purpose. The legislation requires the Secretary to conduct the demonstration for payments made under part A or B of Title XVIII of the Social Security Act (i.e., traditional fee-for-service (FFS) Medicare). Thus the RAC demonstration does not include the audits of payments for Medicare Part C (managed care) or Part D (the prescription drug benefit).

Editor’s note: Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City answered this question.

Top 10 lessons learned from the RAC demonstration program

Andrea Kraynak, CPC-A — Thu, 14 May 2009 04:00:44 +0000

The RAC demonstration project has come and gone, but many providers learned valuable lessons during the process. Consider the following advice from providers and other experts who have experienced RACs first-hand, and lived to tell about it. One of the most important lessons Tanja Twist, MBA/HCM, director of patient financial services for Methodist Hospital in Arcadia, [...]

News: Housing and care coordination reduce hospitalizations

Case Management Weekly — Wed, 13 May 2009 15:13:00 +0000

Offering case management intervention and housing to homeless patients reduced hospitalizations by 29% and ED visits by 24%, according to a May 6 study published in The Journal of the American Medical Association.

Providing care to the homeless has always been a challenge for providers. An estimated 3.5 million Americans likely to experience homelessness during some or all of 2009. This study sought to investigate care coordination solutions for homeless adults with chronic illnesses such as HIV, diabetes, and hypertension.

For the study, patients were provided with hospital social workers for discharge planning, and were placed in transitional housing immediately after a hospital stay. The patients were later transferred to long-term housing.

The study revealed fewer hospitalizations and ED visits for homeless patients who received these case management services than for those who did not receive similar services.

Source: The Journal of the American Medical Association

Prepare case managers for RACs

Case Management Weekly — Wed, 13 May 2009 14:37:00 +0000

CMS’ Recovery Audit Contractor (RAC) project has made it necessary for case managers to become as knowledgeable as possible about denials and appeals. What do you need to do to be prepared for the RAC in your state? Here is a checklist to help you:

Form a RAC committee in your facility. Include a medical advisor and representatives from finance, compliance, billing, and admitting. This committee should be a clearinghouse and review center for all RAC-related activities, including preparing for audits and understanding and determining vulnerabilities.
Perform an internal audit of improper payments. Use findings from the RAC demonstration to help you prepare and identify the areas of vulnerability in your facility by visiting www.cms.hhs.gov/rac.
Conduct a medical records audit of short stays. Examining your one- to two-day stays will help you gain an understanding of prior and present cases, as will the use of standardized clinical leveling criteria to establish the medical necessity of each case.

Check out the May 2009 issue of Case Management Monthly to read the full story, and discover the benefits of becoming a Case Management Monthly subscriber.

May 4-11 Transmittals and MLN Matters articles: CMS clarifies requirement for podiatric treatment, issues MLN Matters articles, and more

Medicare Weekly Update — Tue, 12 May 2009 12:43:00 +0000

CMS Issues Instructions for Recoupment of Overpayments related to MS-DRG 956

On May 8, CMS issued instructions on the mass adjustment of claims for MS-DRG 956 (Limb Reattachment, Hip & Femur Proc. For Multiple Significant Trauma). The Inpatient Pricer had mistakenly identified this DRG as a “special-pay” post acute care transfer DRG. Payment under the “special-pay” methodology resulted in overpayments for discharges that met the criteria for the post acute care transfer rule. The mass adjustments must be completed by August 1, 2009.

Effective date: October 1, 2008
Implementation date: April 27, 2009

View the transmittal.

CMS implements Section 148 of MIPPA regarding outpatient status for a CAH

On May 8, CMS issued a transmittal providing billing instructions based on the new criteria for determining a patient’s outpatient status for a critical access hospital (CAH) or an entity provider-based to the CAH, per Section 148 of the Medicare Improvements for Patients and Providers Act of 2008.

Effective date: July 1, 2009
Implementation date: July 6, 2009

View the transmittal.

CMS clarifies requirement for podiatric treatment

On May 8, CMS issued a transmittal clarifying the requirement for podiatric treatment in Pub. 100-04, Ch. 32, § 80.8. This clarification is necessary to support podiatric coverage requirements found in Pub. 100-02, Ch. 15, § 290.

Effective date: June 8, 2009
Implementation date: June 8, 2009

View the transmittal.

CMS releases MLN Matters articles

CMS released two MLN Matters article related to a transmittal previously outlined in Medicare Weekly Update.

CMS also released a special edition MLN Matters article.

Training Medicare Patients on Use of Home Glucose Monitors and Related Billing Information

April 27-May 4 Transmittals and MLN Matters articles: CMS announces instructions for new discharge status code, and more

Medicare Weekly Update — Tue, 05 May 2009 04:00:00 +0000

CMS issues transmittal on billing for clinical trial services provided to managed care beneficiaries

On May 1, CMS issued a transmittal updating system editing to ensure accurate billing, and ultimately correct pricing of clinical trial services provided to managed care beneficiaries.

Effective Date: October 1, 2009
Implementation Date: October 5, 2009

View the transmittal.

CMS announces deductible application on clinical trial claims

On April 24, CMS issued a transmittal announcing that it is updating the claims processing system to correctly apply or not apply the deductible on clinical trial claims.

Effective date: Dates of service on or after September 19, 2000
Implementation date: October 5, 2009

View the transmittal

CMS announces implementation instructions for new discharge status code

On April 24, CMS issued a transmittal announcing implementation instructions for new patient discharge status code 21 (discharges or transfers to court/law enforcement).

Effective date: October 1, 2009
Implementation date: October 5, 2009

View the transmittal.

View a related MLN Matters article.

CMS releases special edition MLN Matters articles

CMS issued two special edition MLN Matters articles last week:

Q&A: Submitting ABNs

Patient Access Weekly Advisor — Thu, 02 Apr 2009 08:04:00 +0000

Q. Do we include a copy of the Advance Beneficiary Notice (ABN) with the claim form?

A. No, do not submit a copy of the ABN unless requested to do so by the carrier.

Source: Centers for Medicare & Medicaid Services

White House summit concludes with healthcare pledge

Patient Access Weekly Advisor — Wed, 25 Feb 2009 12:19:00 +0000

The White House “fiscal responsibility summit” wrapped up this week with a pledge to determine how to provide health insurance to most Americans.

President Obama said at the end of the summit that he will hold a similar meeting on healthcare next week, focused on how to provide coverage to most of the 47 million uninsured Americans while also finding some savings by reworking the system.

The effort to revamp healthcare and offer insurance to most Americans has been a sort point for Washington politicians for decades.

To read the full Boston Globe story, click here.

Study shows rise in federal healthcare spending

Patient Access Weekly Advisor — Wed, 25 Feb 2009 13:17:00 +0000

A federal study shows that government healthcare spending is expected to increase to $1.191 trillion this year as the recession suppresses private healthcare spending, the Wall Street Journal reports.

The country’s healthcare costs are projected to reach $2.510 trillion overall, a 5.5% increase from 2008, according to the study by economists and actuaries at the Centers for Medicare and Medicaid Services published this week in the journal Health Affairs.

To read the full story, click here.

Keeping aging patients out of the hospital harder than it seems

Case Management Weekly — Wed, 18 Feb 2009 09:26:00 +0000

A recent study aimed at keeping elderly patients with chronic conditions out of the hospital failed, according to a study published in The Journal of the American Medical Association.

CMS hoped that with increased care coordination, elderly patients could receive a clearer care message and be able to care for themselves better, thus reducing the number of hospitalizations required for these patients. In the 15 research programs, conducted from 2002 to 2005, nurses contacted patients regularly in hopes of increasing adherence to care plans and facilitating communication with physicians. The outcomes were measured by the number of hospitalizations and Medicare monthly expenditures. However, 13 out of 15 programs showed no differences in hospitalizations and did not save Medicare a significant amount of money.

Experts say the program failed because changing seniors’ habits is very difficult. The study highlights challenges the healthcare industry faces as the aging population increases.

Sources: The Journal of the American Medical Association, The Washington Times

Insured cancer patients struggle to afford treatment

Case Management Weekly — Thu, 12 Feb 2009 15:15:41 +0000

Patients with cancer undergo many expensive treatments and tests and often find themselves bankrupt even if they have insurance, according to a new report. The report, released by the Kaiser Family Foundation and the American Cancer Society followed 20 typical cancer patients. Of those patients, nine had insurance through an employer, one paid for employer coverage [...]

Survey shows more Americans unable to afford prescriptions in 2007

Case Management Weekly — Thu, 29 Jan 2009 14:40:14 +0000

A recent report by the Center for Studying Health System Change, a nonpartisan policy research organization, states that one in seven Americans under age 65 went without a prescription drug in 2007 because they could not afford it. The study shows the effect increased drug prices were having even before the economic recession went into [...]

Massachusetts governor weighs insurance hearing

Patient Access Weekly Advisor — Thu, 15 Jan 2009 16:14:24 +0000

Massachusetts Gov. Deval Patrick has asked the state’s most prominent hospital and health insurance leaders to take quick action to hold down rapidly rising healthcare costs, suggesting that if they did not take steps on their own, they might face new government regulation, according to the Boston Globe. Patrick said he is considering holding hearings on [...]

Insurers’ profits surpass predictions

Patient Financial Services Weekly Advisor — Mon, 15 Dec 2008 14:55:32 +0000

Health insurance companies for Medicare received $1.3 billion more than projected in 2006, congressional auditors told the Associated Press. The Government Accountability Office said in a report that if projections had been more accurate, much of that $1.3 billion could have gone to better benefits and lower premiums. Read the Associated Press report.

Tip: Guidelines for documenting screening treatment

Compliance Monitor — Fri, 10 Oct 2008 18:24:17 +0000

Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA): For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results). For pregnant women, the medical records should [...]

Illinois governor revises bills to benefit state’s uninsured

Patient Financial Services Weekly Advisor — Fri, 08 Aug 2008 13:57:00 +0000

The governor of Illinois, Rod Blagojevich, announced Wednesday he will revise a bill to allow parents to have their children on their health plan until age 26, the Chicago Tribune reports. Blagojevich says he’s identified more than 50 bills he can revise as part of his “Rewrite to Do Right” campaign, through which he aims to [...]