More changes on the RAC

Modern Healthcare - - Special Report - —Jen­nifer Lubell

Re­cov­ery au­dit con­trac­tors are go­ing to get a lot more per­sonal in their au­dits of hospi­tal providers this year, and the in­dus­try could see fur­ther re­duc­tions in their in­pa­tient pay­ments to ac­com­mo­date a new fed­eral doc­u­men­ta­tion and cod­ing sys­tem.

Out­side of the con­text of larger health­care re­form, which is bound to af­fect any fu­ture reg­u­la­tion on hospi­tal pay­ment, “we do know sev­eral things that will hap­pen re­gard­less of health re­form,” says Don May, vice pres­i­dent of pol­icy with the Amer­i­can Hospi­tal As­so­ci­a­tion.

In May’s view, the three big reg­u­la­tory tar­gets cen­ter on the RAC pro­gram, the pro­posed in­pa­tient prospec­tive-pay­ment rule for 2011, and health in­for­ma­tion tech­nol­ogy, par­tic­u­larly the new “mean­ing­ful use” rule­mak­ing (See re­lated story, p. 8).

No reg­u­la­tory de­vel­op­ment seems to pose greater anx­i­ety to hos­pi­tals than the RAC pro­gram, which al­lows third-party au­di­tors hired by the CMS to keep 9% to 12.5% of provider pay­ments they iden­tify as im­proper.

2010 will be no ex­cep­tion, provider sources say, es­pe­cially since RAC firms will be launch­ing med­i­cal-ne­ces­sity re­views early this year, a type of ad­vanced au­dit that will de­ter­mine whether med­i­cal care given to a pa­tient was ap­pro­pri­ate or not.

Ad­vanced or com­plex au­dits dif­fer from au­to­mated au­dits, which are less-com­plex re­views the RAC firms con­duct that in­volve run­ning data queries and seek­ing im­me­di­ate claims de­nials for things such as providers over­re­port­ing the amount of time it takes to ad­min­is­ter anes­the­sia.

The AHA fears that RAC au­di­tors may end up sec­ond-guess­ing de­ci­sions made by treat­ing physi­cians at hos­pi­tals and pa­tients, de­ci­sions that are of­ten driven by spe­cific and per­sonal cir­cum­stances.

Seek­ing fair­ness

Re­view­ing a de­ci­sion that was made af­ter the fact is a tricky ven­ture, May says. “The key is to make sure there’s fair­ness in the process,” he says. For now, it’s un­clear how ag­gres­sive the RAC au­di­tors will be in driv­ing ac­tiv­ity on med­i­cal-ne­ces­sity re­views, he adds.

Physi­cians have sim­i­lar con­cerns about the RAC pro­gram. The au­dits to date have mainly ze­roed in on hospi­tal au­dits, “but it’s just a mat­ter of time be­fore they’ll start has­sling physi­cian prac­tices,” says Robert Ben­nett, gov­ern­ment af­fairs rep­re­sen­ta­tive with the Med­i­cal Group Man­age­ment As­so­ci­a­tion.

Es­pe­cially in the cases of the med­i­cal-neces- sity re­views, the RAC au­di­tors will be ques­tion­ing de­ci­sions of clin­i­cians, whether it’s in the hospi­tal or pri­vate prac­tice set­ting, Ben­nett says. In in­sti­tut­ing th­ese pro­grams to com­bat crim­i­nal ac­tiv­i­ties in Medi­care to pin­point a very small num­ber of “fly-by-night” providers, the law-abid­ing providers are wor­ried “that they’ll be treated the same way as the crim­i­nals are,” Ben­nett says.

Other types of ad­vanced or com­plex au­dits launched late last year un­der the RAC pro­gram have prompted some early con­cerns that the au­di­tors will be specif­i­cally sniff­ing out ev­i­dence of “up­cod­ing” by providers in 2010.

Cod­ing is­sues will likely drive the CMS to seek fur­ther re­duc­tions to hospi­tal pay­ments un­der its in­pa­tient prospec­tive-pay­ment rule due to be is­sued this spring, May says.

The Medi­care Pay­ment Ad­vi­sory Com­mis­sion, in re­search­ing doc­u­men­ta­tion and cod­ing trends un­der the Medi­care sever­ity-di­ag­no­sis­re­lated groups, or MS-DRGs, im­ple­mented in 2008, found that hos­pi­tals were cod­ing more ac­cu­rately for pro­ce­dures. The new sys­tem, de­signed to bet­ter iden­tify the sever­ity of a pa­tient’s con­di­tion, “cre­ated in­cen­tives to bet­ter doc­u­ment and code secondary di­ag­noses,” ac­cord­ing to MedPAC re­searchers.

Th­ese cod­ing im­prove­ments re­sulted in higher pay­ments—but without any change in pa­tient com­plex­ity or the cost of care. MedPAC’s view is that Medi­care pay­ments shouldn’t have in­creased un­der those cir­cum­stances.

The ad­vi­sory panel, in a draft rec­om­men­da­tion, has sug­gested that a 1% pay­ment re­duc­tion be im­ple­mented an­nu­ally, over eight years, to re­coup over­pay­ments made to hos­pi­tals in 2008 and 2009, and to pre­vent any fu­ture over­pay­ments that would re­sult from doc­u­men­ta­tion and cod­ing im­prove­ments un­der the MS-DRGs.

In­dus­try of­fi­cials be­lieve that the CMS will take MedPAC’s ad­vice se­ri­ously in craft­ing a pos­si­ble ad­just­ment to hospi­tal pay­ments in fu­ture years to off­set the cod­ing im­prove­ments.

What the CMS hasn’t ac­counted for in con­sid­er­ing th­ese re­duc­tions, how­ever, is sever­ity and changes in case mix, May says. The hospi­tal in­dus­try wants the CMS “to ac­knowl­edge that pa­tients are get­ting sicker, as drugs al­low for bet­ter man­age­ment of care in the out­pa­tient set­ting. What that means is peo­ple left in hos­pi­tals are re­ally sick, and the agency hasn’t ac­counted for that.”

In­cen­tive pay

While hos­pi­tals mull th­ese po­ten­tial changes to their re­im­burse­ment, physi­cians in 2010 are ex­pect­ing that more prac­tices will be jump­ing on board a CMS re­port­ing pro­gram that of­fers them a small in­cen­tive for per­form­ing well on qual­ity mea­sures.

The CMS in 2008 paid more than $92 mil­lion in in­cen­tives to doc­tors un­der the Physi­cian Qual­ity Re­port­ing Ini­tia­tive, a vol­un­tary pro­gram that al­lows physi­cians and other el­i­gi­ble health­care pro­fes­sion­als to re­ceive in­cen­tive pay­ments for re­port­ing data on qual­ity mea­sures re­lated to ser­vices fur­nished to Medi­care ben­e­fi­cia­ries.

More than 153,600 pro­fes­sion­als par­tic­i­pated in the 2008 PQRI (the last year for which data were avail­able) and of those, more than 85,000, or 55%, re­ceived in­cen­tive pay­ments, ac­cord­ing to the CMS. As Ben­nett pre­dicts, an even greater num­ber will par­tic­i­pate in 2010, al­though par­tic­i­pa­tion data for last year have yet to be re­leased.

In its fourth year, the PQRI in 2010 of­fers more re­port­ing op­tions to physi­cians, with ad­di­tional mea­sures ap­ply­ing to in­di­vid­ual spe­cial­ties, pro­vid­ing an im­pe­tus to par­tic­i­pate, Ben­nett says.

May: Tar­gets are RAC pro­gram, IPPS rule and “mean­ing­ful use”

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.