Medicaid

HFMA ANI 2008: Advice on preparing for a Medicare audit

Anne Zieger — Wed, 25 Jun 2008 23:30:55 -0400

Today, it's a virtual certainty that you'll come under the watchful eye of Medicare's Recovery Audit Contractors, who have been tasked with investigating providers in all 50 states. The question is, will you be prepared for their arrival--and ready to prove that you're doing things right when they do show up? Too few companies have gotten together the resources they need to take on the RACs, according to Dr. Robert Corrato, MD, MA, president and CEO of Executive Health Resources.

At minimum, organizations should follow the OIG's guidance from a few months ago. In its recent letter, the OIG advises people to work with their accounting firms to decide whether to set aside reserves, examine their records to see whether there are any errors or fraud, and if there are, consult external counsel to see whether they need to self-disclose such errors. (Such disclosures might spare a provider from needing to sign a Corporate Integrity Agreement, Corrato notes.)

However, hospitals in particular should take more steps, including establishing a strong Utilization Review plan and committee which meets the standards of Medicare's Conditions of Participation. The UR plan should address, at minimum, admission review, continued stays and outlier evaluations. Hospitals should also make sure case and UR managers are using the most updated inpatient screening criteria, and use those criteria to see if the facility's patterns fit. Admissions should be screened for medical necessity by such criteria. Cases that don't fall within the criteria should be reviewed by an expert Physician Advisor knowledgeable about Medicare and Medicaid rules, evidence-based care guidelines and medical necessity determinations.

Another important step is to educate treating physicians on the importance of creating complete documentation and working closely with case management and Physician Advisors--and generally speaking, to stress that their cooperation is critical in meeting compliance goals. Also, it's important to make sure the treating physicians communicate well with case managers and Physician Advisors, Corrato suggests.

Ultimately, the process should result in the creation of an "enduring and auditable" document for each Medicare case that proves that your facility has a compliant Medicare admission claim status certification process. Over time, meanwhile, providers will need to keep an eye out for problem cases that fall outside guidelines, and which DRGs pose potential problems. Outliers should be examined and addressed, Corrato notes.

To learn more about the RAC program:
- read this AHA summary

Helping to qualify the uninsured

Anne Zieger — Thu, 19 Jun 2008 03:43:01 -0400

Despite the fact that it's critical for hospitals to qualify uninsured patients for charity care programs ranging from federal and state insurance to institutional programs within your own organization, sometimes it just doesn't happen. However, there will be many vendors at this year's show who hope to improve your track record. One eligibility services vendor who will be attending is Advanced Patient Advocacy, which boasts that it can achieve a minimum of 35 percent reduction of uncollectible receivables. Others, like MedAssist and Eligibility Plus, offer eligibility help as part of a suite of A/R management services. Some companies focus largely on Medicaid and other state programs, while some, like DECO, also extend their services to helping patients pay for care from sources like SSI/SSDI and funding for victims of crime in addition to state and federal insurance programs. Given the bad debt hit most hospitals are taking these days, I suspect these vendors will get an enthusiastic hearing. If given a choice between pursuing self-pay patients on their own, and discovering a better-financed party who will pay for that patient, hospitals would be crazy not to consider choice two.

Hospitals working to avoid non-emergency ED care

Wed, 11 Jun 2008 06:59:58 -0400

As we've noted previously, hospitals are under more intense pressure than ever to avoid bad debt. One strategy, of course, is to collect vigorously after the bill has been incurred. Another, meanwhile, is to help see to it that patients who don't need costly care don't receive it. That's why, in part, that a growing number of hospitals have begun working harder to redirect non-urgent care patients away from costly ED care and over to outpatient clinics.

With primary care access getting spottier--and more and more privately-insured patient showing up in the ED--the ED patient flow burden has only increased of late. Meanwhile, low-income, uninsured, under insured and Medicaid patients continue to head for the ED in growing numbers. According to one study, total emergency visits classified as non-urgent conditions increased from 10 percent 1997 to 14 percent in 2006, according to research by the Center or Studying Health System Change.

To address these issues, hospitals are adopting several strategies targeting non-urgent patients coming to the ED. For example, some have shifted nurse practitioners to screen patients, and to set appointments with outpatient caregivers for those who need it. When patients with non-urgent issues return repeatedly, such nurses can help the ED create care plans that set the patient up with medical homes. In some cases, this can change ED patient inflow dramatically; one Miami ED, for example, referred an average of 50 patients a day to clinics over 18 months, according to the report.

To learn more about this trend:
- read this insideARM article

Related Articles:
Study: ED crowding affects care
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NY Medicaid will stop paying for 'never events'

Wed, 11 Jun 2008 06:59:57 -0400

New York's Medicaid program has decided to stop reimbursing for avoidable hospital complications and medical errors it considers to be "never events." Starting in October, it won't pay for care related to 14 conditions, including wrong-site surgery; foreign objects left in the body; medication errors; blood incompatibility; contaminated drugs and patient disability from electric shock. Hospitals that want to receive Medicaid payments will have to prove that such conditions were present on admission to get paid for treating them. Meanwhile, the state expects to keep expanding this list.

To learn more about New York's decision:
- read this Modern Healthcare report (reg. req.)

Related Articles:
By 2008, Medicare won't pay for hospital errors
Business say 'no pay' for major mistakes
PA hospitals won't charge for 'never events'
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Equity firms partner for $100M buyout of eligibility firm

Wed, 11 Jun 2008 06:59:55 -0400

In a move that further underscores the industry's renewed determination to get patients registered appropriately for state and federal medical programs, a group of private equity firms have partnered to acquire Chamberlin Edmonds & Associates of Atlanta, which provides specialized eligibility determination services to hospitals. It helps hospitals qualify patients not only for Medicaid and federal and state programs, but also, SSI, Society Security Disability and charity care programs, and even crime victims compensation funding.

Chamberlin Edmonds guides uninsured patients through the process of applying for reimbursement for uncompensated care, particularly federal and state disability programs. It has more than 160 customers in 27 states. Chamberlin Edmonds' top executives should remain with the company. The private equity firms involved in the buyout include New York's Charterhouse Group, Highlander Partners and MTS Health Investors. The deal is valued at about $100 million.

To learn more about the deal:
- read this Modern Healthcare article (reg. req.)
- read the equity firms' release

Related Article:
Study: Uninsured ranks could be much lower

Providers make rapid progress on using NPI in claims

Wed, 04 Jun 2008 06:59:58 -0400

When CMS kicked off the National Provider Identifier program a couple of weeks ago, a significant minority of Medicare and Medicaid claims were being rejected--with as many as one-quarter of claims filed bouncing, according to one vendor. Just a week later, however, CMS has reported that providers' filings had gotten much better, fast. According to the agency, most intermediaries were reporting that over 90 percent of claims were NPI-compliant, with some reporting 100 percent compliance. The problems that remained largely involved providers using legacy numbers for their secondary provider identifier field, which should also include the provider's NPI, CMS noted.

To learn more about CMS's report:
- read this HFMA News item

Related Articles:
Claims rejections go through the roof with NPI requirement
Providers want another NPI implementation delay
Smaller providers not ready for NPI
National provider identifier deadline extended

Urban NJ hospitals take big charity funding hit

Wed, 28 May 2008 06:59:57 -0400

A new state formula for funding Medicaid could cut $142 million in charity care payments for treating the uninsured from hospital budgets, taking funding away completely from 22 of the state's hospitals, according to a review of the proposed changes by the New Jersey Hospital Association. The formula, which is part of the state's proposed $33 billion budget, would lead to cuts for a total of 62 hospitals, while boosting up to 18, according to the association. The biggest loser would be Jersey City Medical Center, which would see an almost $42 million cut, or almost 50 percent of its charity care aid. Meanwhile, University Hospital in Newark would get $96.5 million, a boost of just under $400,000. The formula is intended to target the funding to those who need it most, according to the state Department of Health and Senior Services.

To learn more about the proposed fund shift:
- read this article from The Star-Ledger

NY Medicaid losses may force big doctor training cuts

Wed, 21 May 2008 06:59:57 -0400

If an expected moratorium on Medicaid cuts expires next week, it's looking like the state of New York's public and private hospitals will lose upwards of $1 billion in state and federal funds for physician training, according to an analysis by New York city's Independent Budget Office. The change, as proposed by CMS, would end revenue that medical residency programs have relied on for decades. It could have a meaningful impact nationally, too, as New York hospitals have traditionally trained a large number of the nation's doctors, including many who eventually work in poor neighborhoods during their residencies.

In 2006, 40 percent of all Medicaid funds for medical training in the U.S., or $1.36 billion, went to the state of New York. About 15 percent of all U.S. medical residencies, or 16,500, are done in New York state. However, CMS officials said this week that the funds were never intended to pay for medical education, but rather, that states had diverted them to this purpose.

To learn more about the medical training funding gap:
- read this article from The New York Times

Study: Uninsured ranks could be much lower

Wed, 14 May 2008 06:59:56 -0400

I know, you do everything you can to qualify patients for government programs when they're uninsured and need care. Despite that, uninsured patients continue to generate high bad debt levels for providers; in fact, according to the American Hospital Association, the industry provided $31.2 billion in uncompensated care in 2006.

Millions of patients are slipping through screens designed to hook patients up with government programs, according to research by the National Institute for Health Care Management Foundation. For example, one in four who are eligible for Medicaid or the State Children's Health Insurance Program aren't enrolled, a total of about 12 million people.

Of course, the problem doesn't lie just with the provider's eligibility screening process. Often, the uninsured are overwhelmed by the administrative requirements involved in applying for such programs, while current enrollees frequently are dropped when they don't fill out renewal forms. Meanwhile, a 2005 law requiring applicants to show proof of citizenship to be eligible has also led to delays in enrollment for many citizens, foundation researchers said.

To learn more about the report:
- read this InsideARM article

Related Articles:
In 2007, bad debt rising for hospitals
Study: Better records could boost self-pay collections
EDs seeing more affluent patients, less uninsured

Tenet sees $31 million loss for Q1

Wed, 07 May 2008 06:59:57 -0400

Dogged by expenses from lawsuits, Tenet Healthcare announced a $31 million first-quarter loss. Tenet reported a net loss of $31 million for the first quarter of this year, compared with a profit of $75 million for the same quarter last year when it enjoyed a $92 million tax gain. This quarter, Tenet faced litigation costs of $47 million pre-tax, which it set aside for wage and hour lawsuits and other employment matters. On the brighter side, its facilities saw a 1 percent increase in total admissions for this quarter compared to the first quarter of last year. Tenet also saw a drop in charity admissions due to an increased number of patients qualifying for Medicaid.

The unprofitable earnings report doesn't seem to have shocked Wall Street, which actually rewarded the company with a slight gain in its stock price the day the results were released. However, it is something of a counterweight to a recent favorable report from high-profile healthcare analyst Ken Weakly of Credit Suisse Securities, who ranked the stock as "outperform" and predicted a major improvement in its fortunes.

To learn more about Tenet's results:
- read this press release

Related Articles:
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