Revenue Cycle Institute

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.

Tip: Submitting claims for laboratory services

Compliance Monitor — Thu, 19 Nov 2009 05:00:00 +0000

Your hospital should ensure that all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends that your hospital’s written policies and procedures state that:

The hospital bill for laboratory services only after they are performed
The hospital bill only for medically necessary services
The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
The current procedural terminology or Healthcare Common Procedural Coding System code used by the billing staff accurately describes the service ordered
The coding staff submit only diagnostic information obtained from qualified personnel and contact the appropriate personnel to obtain diagnostic information in the event that the individual who ordered the test has failed to provide such information
The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
Routine audits be conducted to assess your billing compliance with the regulations

This week’s tip was adapted from The Compliance Officer’s Handbook 2^nd Edition. For more information about the book or to order your copy, visit the HCMarketplace.

Revenue Cycle Institute releases free RAC Preparedness Benchmarking Report

Andrea Kraynak, CPC-A — Wed, 18 Nov 2009 13:47:44 +0000

Budgets are tight, but it seems that many healthcare providers are aware that setting aside resources to prepare for RAC audits is non-negotiable. HCPro’s Revenue Cycle Institute examined this concept as a part of its recent nationwide survey of RAC readiness. The study, which was released recently, garnered more than 700 participants from all four RAC [...]

Region D RAC approved to audit modifiers -TC and -26

Andrea Kraynak, CPC-A — Tue, 17 Nov 2009 14:12:46 +0000

HealthDataInsights has been approved by CMS to audit for inappropriate billing related to the use of modifiers -TC and -26 on Part B claims in all RAC Region D states. The new issue is as follows: Global vs TC/PC. An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier [...]

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.

Refresh your knowledge of core concepts for coding accuracy

HIM Connection — Tue, 17 Nov 2009 05:00:00 +0000

Clinical knowledge is an essential element for capturing severity and MS-DRG assignment, according to Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM at Kaiser Permanente in Oakland, CA. “When we’re talking about DRG changes and coding changes, it’s important to enhance clinical knowledge,” she said.

Additionally, refresh your knowledge of the following core concepts for coding accuracy:

Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.

“These are great actions to take to ensure accuracy in documentation, case-mix index, and certainly your MS-DRGs,” Bryant said.

Editor’s note: This tip is adapted from the November 2009 issue of Briefings on Coding Compliance Strategies.

Region D RAC adds new DME issue

Andrea Kraynak, CPC-A — Fri, 13 Nov 2009 15:35:35 +0000

HealthDataInsights (HDI) added another new issue approved for RAC audits in all region D states to its Web site. The new issue is as follows: DMEPOS while patient is in a covered Part A inpatient hospital stay. The Web site provides the following explanation of the new issue: For a beneficiary in a Part A inpatient stay, an [...]

Providers report first RAC denials in Florida, South Carolina

Andrea Kraynak, CPC-A — Thu, 12 Nov 2009 19:30:42 +0000

Healthcare providers in several states received their first RAC denials. Connolly Healthcare, the Region C RAC for Florida, South Carolina and several other states, has been behind many of them. One hospital in South Carolina reports having three claims denied. However, learning of those denials did not go smoothly. The hospital received a call in late October [...]

Revenue Cycle Institute posts free coding tool

The RAC Report — Thu, 12 Nov 2009 05:00:00 +0000

Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. We hope you find this month’s tool—a chart of the new ICD-9 codes, including E and V codes—helpful in ensuring you’re on top of the code changes for 2010.

Editor’s note: Access the free tool via the Revenue Cycle Institute Web site by clicking on “Tools.” The chart originally appeared in the October issue of Medical Records Briefing.

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.”

Could RAC mass adjustment changes mean increase in automatic audits?

The RAC Report — Thu, 12 Nov 2009 05:00:00 +0000

Providers who believe their RAC denials will be limited to 200 every 45 days (corresponding with the medical record request limits) may be in for a surprise. Those limits apply only to complex audits, but no such limits exist for the number of automatic reviews RACs can perform.

“RACs can do as many [automated reviews] as they want. I think it is in people’s heads that they can look at only 200 at any one time, but that’s really not true,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

In fact, recent changes to the RAC process for handling mass quantities of recoupments from automatic reviews may even make it easier for RACs to increase their auditing capabilities—meaning the potential for even more denials for providers.

In the past few weeks CMS released three transmittals (R561OTN, R571OTN and R573OTN) detailing several technical changes to “enhance” the RAC mass adjustment process. Essentially, the changes improve the process for the RACs by automating what used to be much more labor-intensive process of initiating mass adjustments of similar claim and/or service types.

“CMS is going to allow RACs to now upload entire files to the intermediary to make mass adjustments, and this is going to make automated denials much quicker for RACs,”

Hoy says. “And whenever you go from manual to automated, you’re going to have a huge increase in efficiency. The changes mean a hospital could get literally thousands of claims denied in one day.”

CMS first came out with a RAC-oriented mass adjustment process in 2007, but the changes should make it easier for the RACs. “Basically they can just run reports now,” Hoy explains.

And if the back-end work involved in processing mass quantities of automatic denials decreases for the RACs, does it mean an increase in their ability to further audit healthcare providers?

We may have to wait until April 5, 2010, when the changes take effect, to find out.

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.

Prepare for miscellaneous costs that may arise during the transition to ICD-10

HIM Connection — Tue, 10 Nov 2009 05:00:00 +0000

Despite an HIM director’s best efforts to prepare for a smooth transition to ICD-10, there may be unforeseen challenges along the way, says Tori Sullivan, RHIA, MHA, PMP, manager of Capgemini Government Solutions in Reston, VA. Having money in reserve is always a good idea. “Set aside money in case you don’t get reimbursed or can’t process claims for a period after go-live,” she advises. Use your hospital’s highest average daily reimbursement and multiply that amount by five. Set aside this amount for reserve in the event of claims submission errors or denials, she says.

One potential challenge for critical access hospitals is the likelihood that ICD-10 will require an encoder, an extra expenditure for hospitals that don’t have one, says Debbie

Mackaman, RHIA, CHCO, regulatory specialist at HCPro, Inc., in Marblehead, MA. “[An encoder] will make things so much easier for coders who are trying to work out of books because it will do an automatic crosswalk for them,” she says.

Editor’s note: This tip is adapted from the December 2009 issue of Medical Records Briefing.

New RAC audit issue for Region D providers

Andrea Kraynak, CPC-A — Wed, 04 Nov 2009 20:10:28 +0000

HealthDataInsights (HDI), added a new CMS-approved issue to its list for all RAC region D healthcare providers. Providers in region D should now be ready for RAC audits of DME claims for the following issue: Infusion Pump Denied/Accessories & Drug Codes should be denied. “When the infusion pump is denied, then the infusion accessories and infusion drug codes are also denied,” [...]

Build accountability into your Revenue Cycle

Patient Access Weekly Advisor — Wed, 04 Nov 2009 19:32:00 +0000

Revenue cycle managers constantly search for the perfect benchmark information to compare their team’s work with others.

Don’t search too hard, says Michael S. Friedberg, FACHE, CHAM, associate vice president of patient access services for Apollo Health Street, a national revenue cycle solutions firm in Bloomfield, NJ.

It can be good to compare nationally or even regionally, but some of the best benchmarks are right under your roof.

Benchmark against yourself, Friedberg said in the September 22, HCPro, Inc. audio conference, “Use Patient Access Benchmarks to Improve Registration Accuracy.” Hold your team accountable. Do you sit back regularly and look at the big picture for your team rather than just put out fires?

In the audio conference, Friedberg pointed to passages in “Leadership,” former New York City Mayor Rudolph Giuliani’s 2002 book, as some great examples of holding staff members accountable.

Guiliani met with the leaders of each of NYC’s police precincts once a week, reviewing crime numbers. If there were a rise in certain crimes, the mayor asked why and what the respective leader was doing about it.

Giuliani built accountability into New York city government. You can build it into your revenue cycle team.

Read the full article.

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.