Medicare claims

Study: 40 percent of hospitals expect to owe money to Medicare under RAC

Anne Zieger — Wed, 03 Sep 2008 11:20:59 -0400

It seems like people aren't very optimistic about their chances of escaping a Recovery Audit Contractor review unscathed, according to a new study. The study, done on behalf of Wolters Kluwer Health, concluded that 40 percent of hospital HIT directors expect to owe funds for Medicare overpayments if audited. The survey found that only 5 percent of HIT directors surveyed think that RAC audits will lead to repayment of funds from Medicare underpayments. Forty-eight percent expect their facility to come out more or less even.

Of the total, 81 percent of the HIT directors said their facilities were working to improve Medicare claims accuracy, including conducting internal audits (77 percent), implementing a documentation improvement plan (66 percent) or creating a special task force to examine documentation, coding and billing practices (57 percent). Meanwhile, 33 percent of hospitals preparing for RAC have installed new software to better capture the right documentation, coding and billing.

To learn more about the study:
- read this Healthcare Finance News piece

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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

CMS now says NPI must match IRS data

Anne Zieger — Wed, 18 Jun 2008 00:40:09 -0400

Providers have been going through some serious headaches already working to make sure they use their National Provider Identifier number properly to avoid getting claims bounced by Medicare. Now, CMS has raised the stakes again. In a move that surprised most observers, the agency announced that doctors will have to reconcile their NPI data with their IRS legal name data if they want to get their Medicare claims paid.

This is an extremely stringent requirement that should prove quite difficult to meet, experts say. Every aspect of a doctor's data must match in both databases, including exact name spellings, use of initials and even any blank spaces in the data. This new requirement only makes things worse for providers, many of whom continue to have trouble getting CMS to tell them why their claims are bouncing. All CMS will tell most physicians with NPI troubles is to start again with a new NPI enrollment, which could take months to process. Now, with the new and unexpected demand to match IRS data, providers could be faced with yet another reason for getting another NPI number.

To find out more about the new requirement:
- read this Healthcare Finance News article

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