12. September 2014 16:24
Four Hospitals have Accepted So Far – Will Yours Be Next?
To help break the log jam of appeals hung up across the country with Administrative Law Judges taking 24 months or longer to rule on them, CMS offers to make a deal with hospitals (excluded from the offer are cancer hospitals, children’s hospitals, inpatient rehabilitation facilities, psychiatric inpatient facilities).
If eligible hospitals file a settlement agreement request by Oct. 31, 2014, then CMS will provide those hospitals with a partial payment of 68% of the net allowable amount for those inpatient claims CMS announced Tuesday, September 9, 2014.
Hospitals may not file for the settlement of some claims and continue to appeal others.
CMS updated its FAQ on Sept. 9 to make the following key points:
- No settlements are in the works for appeals of coding denials.
- Providers not filing a settlement request will remain in the normal appeals process.
- This is a one-time settlement offer. Participating in the settlement offer is completely voluntary.
- Claims that have already been reviewed are always excluded from future review by a MAC and Recovery Auditor. Because CERT chooses claims randomly, it is possible that a handful of these claims will be selected for CERT review. This settlement does not impact reviews being conducted under the false claims act, so ZPIC or OIG reviews of potentially fraudulent claims will continue.
As of September 9, four providers had submitted settlement requests. CMS said, “All passed the "eligible hospital" test and have been forwarded to the appropriate Medicare contractor for validation.”
What are your feelings about this offer? Fair or unfair?
Will it really help resolve healthcare costs for the nation, or hurt the fiscal ability of hospitals to maintain the best facilities, physicians, staff and newest technologies to provide emergency and care service lines to their communities?
We’d love to hear from you.
11. September 2014 16:24
This was one factor in the OIG’s decision to partially restart the RACS, which merits discussion.
If audit responses efficiently managed, and charges are fully current, compliant, and documented, and then auditors won’t benefit from the costly administrative nightmare that many of the less scrupulous external auditors are causing when they perform, as the OIG puts it, “duplicative postpayment claims reviews.” Read more: http://www.gao.gov/assets/670/664880.pdf
CMS points out that these are,“.. reviews of the same claims that are not permitted by the agency—but CMS neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplication.”
What can a healthcare organization do about this?
The best defense is a good offense:
- Get your documentation standards in place – always document the “risk” component and treatments.
- Get your claims right the first time and then - if audited - appeal, appeal, appeal.
- By performing your own internal audits, you can validate that your charges are fully current, complete and compliant. Don’t leave money on the table with missed charges through lack of internal oversight. You don’t want to risk getting it wrong, remember that noncompliance – even through error – is called fraud today.
Healthcare organizations’ internal auditors need to be more aware & competent that ever before.
No longer can healthcare organizations live on just Medicare. Today, awareness of Medicaid & Commercial payor plans is very necessary. Commercials are tough. The ever–changing rules from commercial payors make it very difficult. Plus, unlike Medicare, commercial payors don’t typically provide solid rules. This means healthcare organizations must piece the rules together themselves. And commercial payors generally have a poor way of communicating their rules to healthcare organizations’ auditors.
Tip to healthcare internal auditors: When reviewing claims make sure you review them from the perspective of the specific payer on the claim. Always have your contract on hand when meeting with any external auditor auditing commercial claims – it can stop a lot of line-item denials before they start!
What are your experiences with meeting commercial payors’ requirements for reimbursable claims? What are some areas where you feel that your healthcare organization’s audit prevention initiatives can be improved? Think I missed something important? Let me know in the comments or tweet us @RIJourney with your ideas.
15. August 2014 13:25
The July 2014 GAO highlight report on Medicare Program Integrity entitled, “Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews,” can be read online here: http://www.gao.gov/assets/670/664880.pdf
This report essentially says that CMS, “…has taken steps to prevent its contractors from conducting certain duplicative post-payment claims reviews—reviews of the same claims that are not permitted by the agency—but CMS neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplication.”
So, since the administrative cost-pressure from duplicative audits won’t lessen any time soon, getting optimal processes and tools in place for managing duplicative audits - both efficiently and effectively - is essential. Remember - even an error is considered fraud today.
Check out the Craneware Benchmark Series: Key Indicators of Revenue Integrity Excellence to learn more about recovery audits, understand how well your organization is performing against Craneware standards and, equally importantly, gather step-by-step best practices to minimize compliance risk and optimize financial performance.
If your organization is “seeing double” with duplicative audits, what approaches are helpful and what insights would you share with others on the Journey to Revenue Integrity?