Revenue Cycle Institute » Medicare compliance

New report reveals $47 billion in Medicare fraud

Compliance Monitor — Fri, 20 Nov 2009 05:00:00 +0000

The government paid over $47 million in questionable Medicare claims – nearly three times the amount from last year, according to a new federal report, obtained by The Associated Press (AP).

The improper payments are the largest waste of taxpayer dollars in the $440 billion Medicare program’s 20 year history, according to the report.

According to the AP, the Health and Human Services Department’s stricter documentation requirements caused the increase, not an actual rise in Medicare fraud. The AP reports that in the near future, President Obama will announce new initiatives to defend against Medicare fraud, including the launch of a government Web site detailing healthcare spending and improper payments by various health agencies.

The Obama administration has set its goal of reducing improper Medicare payments at 9.5%. This projected target would save taxpayers a total of $9.7 billion.

More on deductibles and coinsurance

Medicare Weekly Update — Tue, 17 Nov 2009 05:00:00 +0000

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS recently published the Part A deductible and coinsurance and Part B deductible amounts for CY 2010. For most covered inpatient stays, as well as covered outpatient services, Medicare does not pay the entire Medicare allowable for those stays or outpatient services. Beneficiaries generally are responsible for a portion of the Medicare allowable in the form of deductibles and/or coinsurance.

Under Part A, Medicare beneficiaries are entitled to 90 regular benefit days per benefit period. Regular benefit days renew whenever a new benefit period begins. That is, a patient once again has 90 covered inpatient days every time a new benefit period begins. Medicare beneficiaries are also entitled to 60 lifetime reserve days, which may be used after regular benefit days for that benefit period have been exhausted. Lifetime reserve days do not renew. Once used, they are gone forever.

Click over to the MedicareMentor Blog to read more.

CMS Public Events: Hospital Open Door Forum

Medicare Weekly Update — Tue, 17 Nov 2009 05:00:00 +0000

The next Hospital & Hospital Quality Open Door Forum is scheduled for 2 p.m. Eastern, Thursday, November 19. To access the call, 800/837-1935 and reference conference ID: 34708559.

A transcript and audio recording of the conference call will be available to MedicareFind subscribers approximately one week after the Open Door Forum is held.

RAC vs. CERT audits: Do you know the difference?

The RAC Report — Thu, 12 Nov 2009 06:00:00 +0000

The Comprehensive Error Rate Testing (CERT) Hospital Payment Monitoring Program is one of the ways CMS is trying to improve the quality and accuracy of Medicare claim submission and payment of those claims. Is that so different from what the RAC program is designed to do?

While the end-goal may be the same, the methodology is very different. Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City, outlines some of the important differences between the two types of Medicare audits:

Who is being audited. RACs look for errors made by providers, but the CERT is looking for errors in payments made by carriers. Hospitals and other providers are affected because when the CERT looks into a claim, the provider must submit the medical records, and if the CERT uncovers an error, the CERT will take back money from the hospital. But the CERT is really looking for errors made by fiscal intermediaries, Medicare administrative contractors, or other carriers when paying providers’ Medicare claims.
Education. “CERTs want to make sure everything is on the up and up for the claims,” Levitt explains. When the patterns of incorrectly paid claims appear on its radar, the CERT steps in and educates providers. RACs don’t provide such education.
Payment. RACs are paid through contingency fees. The more under- or over-payments they uncover, the more money they receive. The payment for CERTs is different; they receive a set amount outlined in their contract, regardless of the percentage of payment errors they find.
Size of the program. The RAC program has gotten much more attention than the CERT program, but it may be because the RAC program has the potential to be a much bigger headache for providers. The CERTs examine random claim samples—often only looking at a very small percentage of a carrier’s claims. So the CERT would likely request only a small number of medical records from providers paid by that carrier. And the potential takeback, if any, would likely be smaller as well.

However, there are some similarities between the two programs. Both auditors report to CMS. And both will recoup money from hospitals and other providers who received overpayments.

Providers can also appeal any claims they believe were wrongly denied by a RAC or CERT. The process for RAC appeals has been widely discussed, but providers can also go through the appeal process for a CERT denial. “It’s not just a de facto takeback,” Levitt says.

In addition, CERTs will still use OIG statistical methodology. “They’re still bound to that just like the RAC is—for example if a RAC wants to extrapolate,” she notes. “Everybody is held to the same statistical standard such as the OIG statistic program, RATSTATS.”

Clearing up condition code 44 confusion

Case Management Weekly — Wed, 11 Nov 2009 05:00:00 +0000

Hospitals must meet certain criteria before they use condition code 44. Consider this example. A patient experiencing chest pain presents to a hospital Saturday night. The hospital does not have weekend case management coverage, so the physician admits the patient as an inpatient. During this time, the physician orders tests, chest x-rays, and other services.

Upon reviewing the case on Monday, the utilization review (UR) committee determines that the patient did not require inpatient admission. Note that the UR committee may never use InterQual or Milliman criteria to deny an admission. Before the hospital can assign condition code 44 and change the patient’s status, it must meet the following requirements:

The change in patient status from inpatient to outpatient is made prior to discharge or release while the beneficiary is still a patient of the hospital
The hospital has not submitted a claim to Medicare for the inpatient admission
A physician concurs with the UR committee’s decision, and his or her approval is documented in the patient’s medical record

If the hospital fulfills these requirements while the patient is still in the building, condition code 44 will allow the hospital to go back and bill all medically necessary Part B services ordered by the physician as if they had been provided in the outpatient setting. The hospital will receive payment via the outpatient prospective payment system. If the hospital cannot fulfill these requirements, it can only bill for Part B diagnostic services.

Check out the November 2009 issue of Case Management Monthly to learn more about condition code 44 requirements. You also can discover the benefits of becoming a Case Management Monthly subscriber.

For even more condition code 44 information, join HCPro December 15 for an audio conference, “Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance.” Visit the HCMarketplace to register for this program.

ZPICs have begun in Zone 4

Case Management Weekly — Wed, 11 Nov 2009 05:00:00 +0000

The following article is excerpt from HCPro’s newest resource for hospital case managers—www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

Health Integrity LLC, the Zone Program Integrity Contractor (ZPIC) for Zone 4 (Colorado, New Mexico, Oklahoma, and Texas) has begun requesting medical records for review.

ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. ZPICs may “take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped,” according to the Medicare Program Integrity Manual.

During HCPro’s November 3 audio conference, “Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review”, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.

This information was not that surprising to Robert Wade, Esq., a partner at Baker and Daniels, LLP, in South Bend, IN. ZPICs have authority to begin reviews as soon as they are awarded a contract. Health Integrity became the Zone 4 contractor during February.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

Signature for Laboratory Tests, Clarification in the MPFS Final Rule

Medicare Weekly Update — Tue, 10 Nov 2009 05:00:00 +0000

This week, I would like to review a “clarification” regarding physician signatures on orders for clinical diagnostic testing that came out in the Final Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for 2010. Although this publication is hospital-directed and we do not normally report on physician fee schedule issues, this “clarification” could affect hospital policies on obtaining signatures for the laboratory services they provide.

Click over to the MedicareMentor Blog to read more.

CMS extends comment period for proposed ESRD PPS

Medicare Weekly Update — Tue, 10 Nov 2009 05:00:00 +0000

CMS extends ESRD PPS comment period

On November 4, CMS published a notice in the Federal Register to extend the comment period on its proposal to initiate a prospective payment system (PPS) for end-stage renal disease (ESRD). The comment period on the ESRD PPS proposed rule will now end at 5 p.m., December 16.

View the notice of extension.

Submit a comment.

HCCA survey results show effects of economy on compliance

Compliance Monitor — Wed, 04 Nov 2009 05:00:00 +0000

In 2008, the Healch Care Compliance Association (HCCA) conducted a survey with members of the compliance profession to share their expectations of the impact of the economy on compliance in 2009. Click here to view the results.

As 2009 closes, HCCA looks to compliance professionals to see how the economy will affect business in 2010. To participate in this study, and to compare and contrast your plans with the rest of the compliance community, take the three minute survey here.

CMS releases 2010 OPPS final rule

Lori Levans — Tue, 03 Nov 2009 20:24:03 +0000

The 2010 OPPS final rule released on October 30 contains few surprises, but does finalize two changes that received considerable attention when CMS proposed them. “The information CMS has finalized for physician supervision and drug reimbursement are two key areas for hospital review, though for slightly different reasons,” says Jugna Shah, MPH, president of Nimitt Consulting [...]

CMS issues 2010 final rule for ambulatory surgery centers and most hospital outpatient departments

Medicare Weekly Update — Tue, 03 Nov 2009 05:00:00 +0000

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS has released a display copy of the outpatient prospective payment system (OPPS) final rule for 2010, which also includes the 2010 changes to the rules for ambulatory surgery centers (ASCs). This final rule will be published in the Federal Register on November 20. In terms of reimbursement, OPPS hospitals that meet quality indicator reporting requirements for 2010 are entitled to the “full update,” which will result in a 2.1% increase in their payments for 2010. Those OPPS hospitals that do not meet their quality indicator reporting requirements will be subject to a reduced update of 0.1% in 2010. ASCs, on the other hand, will receive a 1.2% inflation update beginning January 1, 2010.

Among the most anticipated changes in the OPPS final rule are the so-called “incident to” a physician’s services requirements. Most nonphysician outpatient therapeutic services that are provided by hospitals or critical access hospitals (CAHs) are only covered if they are provided “incident to” the services of a physician or another specified nonphysician practitioner.

Click over to the MedicareMentor Blog to read more.

Revenue Cycle Institute Announces New Medicare Membership Program

Andrea Kraynak, CPC-A — Fri, 30 Oct 2009 04:00:26 +0000

The Revenue Cycle Institute has new membership program for healthcare organizations that face challenges managing Medicare rules and regulations. The program offers ongoing access to regulatory experts for analysis, guidance, and tailored on-site education for their revenue cycle teams. “Clients have been asking us for an on-call resource to get their unique Medicare questions answered,” said Lori Levans, [...]

OIG plans to review Medicare, Medicaid auditing programs

Andrea Kraynak, CPC-A — Thu, 15 Oct 2009 04:00:32 +0000

Healthcare providers are finding themselves and their reimbursement claims accountable to more and more auditors as CMS steps up its Medicare and Medicaid auditing activities. And CMS is unlikely to decrease auditing for incorrectly paid claims anytime soon; it too is being held accountable—by the Office of Inspector General (OIG). In 2010, the OIG plans to [...]

Revenue Cycle Institute unveils RAC preparedness survey results

Andrea Kraynak, CPC-A — Wed, 14 Oct 2009 18:23:18 +0000

The Revenue Cycle Institute has issued a report on a nation-wide survey of hospitals about their efforts to prepare for the permanent RAC program. More than 700 hospitals nationwide participated in the survey. While 71% of hospitals responding said they have a formal RAC preparedness program in place, the majority of programs were still in the early stages of development, focusing [...]

RAC News: New issues for region D, CMS announces Town Hall meeting, and AHA releases program update

Andrea Kraynak, CPC-A — Wed, 07 Oct 2009 13:43:24 +0000

New issues for RAC Region D HealthDataInsights (HDI) has announced two new issues for region D. HDI can now audit DME providers in all region D states for the following two issues: Urological bundling Wheelchair Bundling For more information on these issues, visit the HDI Web site. As always, the latest RAC issues for each state are posted on the Revenue [...]

September 28-October 5 Issuances: OIG issues 2010 Work Plan, CMS updates lab NCDs and RAC FAQ

Medicare Weekly Update — Tue, 06 Oct 2009 04:00:00 +0000

OIG issues Work Plan

On October 1, the OIG issued its Work Plan for FY 2010.

View the Work Plan.

CMS updates lab NCDs

CMS has posted the October 2009 update to its lab NCDs.

View the lab NCD manual.

New RAC FAQ

CMS released several new/updated FAQs, including the following:

If I am a chain provider whose FI is WPS (serving as the national fiscal intermediary) who will my Recovery Audit Contractor (RAC) be?

Read the answer.

September 21-28 Transmittals and MLN Matters articles: CMS updates drug HCPCS hook and hold, rescinds/replaces transmittals, and more

Medicare Weekly Update — Tue, 29 Sep 2009 04:00:00 +0000

CMS rescinds, replaces LCD exception transmittal

On September 25, CMS replaced its previous transmittal on LCD exceptions. It had previously sent out the incorrect version of section 3.12. All other material remains the same.

Effective date: October 13, 2009
Implementation date: October 13, 2009

View the transmittal.

CMS rescinds, replaces transmittal on NCDs for surgical never events

On September 25, CMS replaced its previous transmittal on its surgical never event NCDs. CMS made several clarifications in the new issuance.

Effective date: January 15, 2009
Implementation date: July 6, 2009, for B MACs and carriers; October 5, 2009, for A MACs, FIS, and FISS

View the transmittal.

CMS updates OPPS hook and hold for certain drug HCPCS

On September 25, CMS issued instructions to update the hook program for certain drug HCPCS codes.

Effective date: January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

MLN Matters article

CMS released a special edition MLN Matters article on influenza resources.

2009 - 2010 Seasonal Influenza (Flu) Resources for Health Care Professionals

Condition Code 44 – The Next Chapter

Medicare Weekly Update — Tue, 29 Sep 2009 04:00:00 +0000

Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

After CMS issued Transmittal 1803, we have continued to receive questions on the correct way to bill for outpatient services when Condition Code 44 criteria have been met. The next chapter of the story involves determining if and when observation begins.

Click over to the MedicareMentor Blog to read more.

September 14-21 Transmittals and MLN Matters articles: CMS rescinds/replaces transmittals, issues special edition MLN Matters

Medicare Weekly Update — Tue, 22 Sep 2009 12:44:00 +0000

CMS replaces FDG PET transmittals

On September 18, CMS rescinded and replaced two previous transmittals related to FDG PET coverage.

Effective date: April 6, 2009
Implementation date: October 19, 2009

View the transmittal to the Claims Processing Manual.

View the transmittal to the National Coverage Determinations Manual.

CMS replaces IPPS update transmittal

On September 17, CMS rescinded and replaced its previous transmittal to update the IPPS.

Effective date: Discharges on or after October 1, 2009
Implementation date: October 5, 2009

View the transmittal.

View a related MLN Matters article.

MLN Matters article

CMS issued a Special Edition MLN Matters article.

Visit Requirements Clarification for CR 5931 “Manualization of Payment for Outpatient ESRD Related Services”

CMS clarifies RACs’ ‘exception authority’

Medicare Weekly Update — Tue, 22 Sep 2009 12:28:00 +0000

Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim. However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim. This is a good time to review the difference between a national and a local coverage determination policy.

Click over to the MedicareMentor Blog to read more.