Scal­ing back scru­tiny

Fla. hospi­tals wel­come pre­pay­ment re­view shift

Modern Healthcare - - THE WEEK IN HEALTHCARE - Joe Carlson

Florida has one of the high­est rates of er­ro­neous Medi­care claims in the na­tion, but the state’s Medi­care ad­min­is­tra­tive con­trac­tor is scal­ing back plans to con­duct pre­pay­ment re­views of claims in his­tor­i­cally prob­lem­atic cat­e­gories.

Al­though gov­ern­ment of­fi­cials have been clam­or­ing in re­cent years to snuff out in­ap­pro­pri­ate pay­ments in fraud hot spots such as Florida, some providers said the ini­tial pro­posal by Medi­care con­trac­tor First Coast Ser­vice Op­tions would have choked off their cash flow. Of­fi­cials say hospi­tals may find the scaled-back re­views of billing mis­takes eas­ier to swal­low.

Last Novem­ber, First Coast—a wholly owned sub­sidiary of Blue Cross and Blue Shield of Florida—an­nounced plans aimed at slash­ing the state’s er­ror rate in Medi­care pay­ments by re­view­ing ev­ery claim filed un­der 15 mis­take-prone codes for car­diac and or­tho­pe­dic cases start­ing Jan. 1 and not pay­ing those bills un­til its au­di­tors were sat­is­fied that pa­tient records jus­ti­fied the care.

But in a Jan. 19 an­nounce­ment, First Coast re­vealed to Medi­care providers in the state that it would re­view only 30% of the claims in 14 of the 15 DRGS and 50% of the claims in one DRG, ma­jor joint re­place­ment with­out ma­jor com­pli­ca­tions.

First Coast’s an­nounce­ment didn’t give a rea­son for the change. A spokes­woman for the com­pany de­clined re­peated re­quests for com­ment and re­ferred all ques­tions about the change to the CMS.

Asked whether fed­eral of­fi­cials told First Coast to back down from its 100% pre­pay­ment re­view ini­tia­tive an­nounced in Novem­ber, a CMS of­fi­cial said last week that the agency did re­mind the Florida con­trac­tor about the CMS’ re­quire­ment that cor­rec­tive ac­tions to root out fraud be con­ducted in a “pro­gres­sive” way that in­creases the scru­tiny over time in di­ag­noses that don’t im­prove.

“We may have re­minded First Coast to make sure they were do­ing those re­views in ac­cor­dance with the pro­gres­sive cor­rec­tive ac­tions re­quire­ment,” said Me­lanie Comb­sDyer, deputy di­rec­tor of the Provider Com­pli­ance Group in the CMS’ Of­fice of Fi­nan­cial Man­age­ment.

That pro­vi­sion in the Medi­care Pro­gram In­tegrity Man­ual re­quires ad­min­is­tra­tive con­trac­tors to use data-driven anal­y­sis to fig­ure out how to ap­ply med­i­cal re­views. Comb­sDyer said it al­lows for a “ratch­et­ing up” of cor­rec­tive ac­tions such as pre­pay­ment re­view in cases where per­for­mance does not im­prove.

First Coast’s Jan. 19 no­tice says it may in­crease the per­cent­ages of claims for pre- pay­ment re­view to more than 30% in the fu­ture. Most of the re­views started Jan. 1 or will start by Feb. 1.

“For now, it sounds to me like that’s the ap­pro­pri­ate amount of re­view,” Comb­sDyer said of First Coast’s an­nounce­ment.

The 15 DRGS se­lected for pre­pay­ment re­view in­clude: im­plan­ta­tion of per­ma­nent pace­mak­ers and car­diac de­fib­ril­la­tors; per­cu­ta­neous car­dio­vas­cu­lar pro­ce­dures with druge­lut­ing stents; some spinal fu­sions; ma­jor joint re­place­ments with­out ma­jor com­pli­ca­tions; and claims for chest pains, a Dec. 11 First Coast re­port says.

De­spite op­po­si­tion from physi­cian groups and some providers, an of­fi­cial with the Florida Hospi­tal As­so­ci­a­tion said hospi­tals could ac­tu­ally sup­port the con­cept of pre­pay­ment re­views be­cause they oc­cur in near real-time.

The rapid turn­around time would be a ma­jor im­prove­ment over the con­tro­ver­sial Medi­care Re­cov­ery Au­dit Con­trac­tor Pro­gram un­der which a ret­ro­spec­tive re­view process can in­clude claims go­ing back years. Kathy Reep, vice pres­i­dent of fi­nan­cial ser­vices for the Florida Hospi­tal As­so­ci­a­tion, said the lag time in the RAC process al­lows hospi­tals to con­tinue sub­mit­ting in­cor­rect bills in­stead of dis­cov­er­ing prob­lems quickly.

Combs-dyer said pre­pay­ment re­view was also be­ing en­cour­aged be­cause it cuts the ac­tual Medi­care pay­ment er­ror rate, un­like ret­ro­spec­tive re­views, which can re­coup money but not retroac­tively de­crease the num­ber of er­rors.

The CMS’ Com­pre­hen­sive Er­ror Rate Test­ing an­a­lysts es­ti­mated that 8.6% of all Medi­care hospi­tal in­pa­tient claims were paid in er­ror in 2011. In Florida, the over­all er­ror rate was es­ti­mated at 13.4% in 2010, the most re­cent year for which state-spe­cific data were avail­able.

Pres­i­dent Barack Obama or­dered agen­cies to re­duce im­proper pay­ments in fed­eral pro­grams in a 2009 ex­ec­u­tive or­der.

The CMS’ Medi­care ad­min­is­tra­tive con­trac­tors—which were for­merly called fis­cal in­ter­me­di­aries—across the coun­try have since then been in­creas­ing their scru­tiny of er­ror rates, al­though First Coast’s now-can­celed 100% pre­pay­ment re­view pro­gram grabbed the head­lines, fol­low­ing op­po­si­tion from groups in­clud­ing the Florida chap­ter of the Amer­i­can Col­lege of Car­di­ol­ogy.

The Florida pre­pay­ment re­view pro­gram doesn’t ini­tially af­fect physi­cian pay­ments. How­ever, First Coast warned in pub­li­ca­tions to providers that if a hospi­tal’s pay­ment was de­nied, the agency will is­sue “re­coup­ment” let­ters start­ing Feb. 1 de­mand­ing re­pay­ments from doc­tors in­volved in the er­ro­neous episode of care.

Dr. Jerold Saef—a car­di­ol­o­gist at Bay Pines (Fla.) Vet­er­ans Af­fairs Med­i­cal Cen­ter and head of the Third Party Payer Com­mit­tee of the Florida Chap­ter of the Acc—said such pre­pay­ment re­views could cause havoc with Florida providers’ cash flow dur­ing the 60-day pre­pay­ment re­view pe­riod.

“We have a lot of con­cerns,” Saef said. “This pre­pay­ment au­dit … car­ries the po­ten­tial for physi­cian prac­tices of hav­ing a dev­as­tat­ing im­pact.”

De­spite that sen­ti­ment, the Florida Hospi­tal As­so­ci­a­tion’s Reep said hospi­tals “def­i­nitely sup­port” hav­ing physi­cians’ re­im­burse­ment put in jeop­ardy in cases where hospi­tals’ bills are also de­nied.

“The physi­cians are do­ing the doc­u­men­ta­tion,” Reep said. “If the physi­cian is not pro­vid­ing ap­pro­pri­ate doc­u­men­ta­tion that causes pay­ment to be com­pro­mised, you are not go­ing to get the physi­cian to change their be­hav­ior if their pay­ment is not af­fected.”

One of the 15 DRGS get­ting pre­pay­ment re­view in Florida is im­plan­ta­tion of per­ma­nent pace­mak­ers.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.