Build­ing mo­men­tum

RAC re­cov­er­ies grow as pro­gram ex­pands

Modern Healthcare - - THE WEEK IN HEALTHCARE - Melanie Evans

Au­dits that have turned up more than $680 mil­lion so far in Medi­care pay­ment er­rors started slowly in the first year, a new re­port shows. More re­cent data sug­gest au­di­tors have grown more ag­gres­sive as the pro­gram pre­pares to ex­pand.

The first re­port to Congress on Medi­care’s Re­cov­ery Au­dit Con­trac­tor Pro­gram, re­leased in late Septem­ber cov­er­ing the fed­eral fis­cal year be­gin­ning Oct. 1, 2009, pro­vides an over­view of au­di­tors’ first year as fed­eral of­fi­cials move to broaden au­dits un­der Medi­care and ex­pand them to Med­i­caid, and as Congress seeks ways to fur­ther curb fed­eral spend­ing.

The Pa­tient Pro­tec­tion and Af­ford­able Care Act ex­panded au­di­tors’ reach from Medi­care fee-for-ser­vice to in­clude Medi­care man­aged care and pre­scrip­tion drug cov­er­age. No date has been set for those au­dits to be­gin.

Med­i­caid au­dits, an­other of the Af­ford­able Care Act’s pro­vi­sions to re­duce fraud, are sched­uled to start next Jan­uary and re­coup $2.1 bil­lion over five years. Fed­eral of­fi­cials fi­nal­ized reg­u­la­tions for the ef­fort last month (Sept. 19, p. 8).

Medi­care re­couped more from au­di­tors dur­ing the first quar­ter of fis­cal 2011, which be­gan Oct. 1, 2010, than it did the en­tire prior year, ac­cord­ing to fed­eral fig­ures not in­cluded in the re­port.

Providers re­turned $ 81.2 mil­lion to Medi­care be­tween Oc­to­ber and De­cem­ber last year (the first quar­ter of fis­cal 2011) and $499.6 mil­lion dur­ing the first nine months of fis­cal 2011. That’s com­pared with $75.4 mil­lion dur­ing all of fis­cal 2010, the re­port to Congress said.

For hos­pi­tals, ten­sion has grown dur­ing the pro­gram’s sec­ond year as au­di­tors have in­creas­ingly re­viewed bills for whether care was med­i­cally nec­es­sary, forc­ing providers to de­fend treat­ment de­ci­sions months af­ter the fact, said El­iz­a­beth Bas­kett, se­nior as­so­ci­ate di­rec­tor for pol­icy at the Amer­i­can Hos­pi­tal As­so­ci­a­tion. Pay­ments deemed as im­proper for rea­sons of med­i­cal ne­ces­sity can be sig­nif­i­cant, she said.

Au­di­tors were not fully up and run­ning dur­ing the first year and as au­di­tors grew more es­tab­lished in 2011, the amounts grew, she said.

Bas­kett also ques­tioned the re­port’s claim that the pro­gram saw few ap­peals, which would sug­gest the Medi­care au­di­tors proved highly ac­cu­rate.

Hos­pi­tals have ap­pealed 5% of claims in 2010 and $2.6 mil­lion, or 2.5%, of au­dited claims were over­turned, ac­cord­ing to the re­port. An on­go­ing AHA sur­vey, launched in Jan­uary 2010, found roughly 25% of hos­pi­tals filed an au­dit ap­peal, said Bas­kett, who has con­tacted the CMS with ques­tions about its data. She said AHA of­fi­cials be­lieve Congress should have in­for­ma­tion about the time and money spent on lengthy ap­peals.

Amy Nor­deng, govern­ment af­fairs coun­sel for the Med­i­cal Group Man­age­ment As­so­ci­a­tion, also ques­tioned ap­peals data. Doc­tors ac­counted for $5.4 mil­lion of the amount au­di­tors col­lected (See chart) and av­er­age claims ranged from $106 to $157 in dif­fer­ent re­gions. Nor­deng said doc­tors may not find an ap­peal for such small claims worth­while. She also said doc­tors have seen an in­crease in au­di­tors’ ac­tiv­ity.

Four com­pa­nies that au­dit Medi­care fee-forser­vice pay­ments, one for each of four U.S. re­gions, were paid a per­cent­age of the amount Medi­care re­cov­ers, roughly 9% to 12.5%.

The AHA’s Bas­kett said hos­pi­tals have urged the CMS to use re­cov­ered pay­ments to an­a­lyze its com­plex billing sys­tem and find ways to re­duce mis­taken pay­ments. Hos­pi­tals, she said, also could ben­e­fit from greater trans­parency on com­mon billing er­rors.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.