CMS: New Improper Payment Edits Coming July 1, 2012

Recently, CMS released Transmittals 1051, Change Request 7661 (replacing Transmittal 1033) titled “Analysis of Improper Overpayments to Design Edits to Correct These Overpayments in CWF, MCS and FISS.” The new edits are the result of “significant improper payments and require the development of edits to correct improper payments” as discovered by – you guessed it – the OIG and RAC. No one is immune; the new edits will target physician place of service codes, E/Ms during the global period and hospital transfers among others. CMS is implementing edits for all claim types to recover payments.

For more, go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1051OTN-.pdf

‘Big Data’ Initiative and Healthcare

On March 29, 2012, President Obama’s administrators announced the $200 million dollar R&D investment in the ‘big data’ project.  According to the press release, the “Big Data Research and Development Initiative” will “improve our ability to extract knowledge and insights from large and complex collections of digital data”. It further suggests that this project will “help solve some of the Nation’s most pressing challenges.”  The project is a joint collaboration with the Office of Science and Technology and other agencies and is supported by the National Science Foundation (NSF) and the National Institute of Health. NIH is “particularly interested in imaging, molecular, cellular, electrophysiological, chemical, behavioral, epidemiological, clinical, and other data sets related to health and disease.” Read the press release here.

CMS Says: Do Yourself a Favor – Return the Overpayment

On Valentine’s Day, CMS sent a love note to the industry in the guise of a proposal, informing it of  the need to report and return self-identified overpayments  within 60 days of the incorrect payment identification or “on the date when a corresponding cost report is due, whichever is later.”

Twice before, in 1998 and 2002, CMS tried to enact changes to the amendment regulating recoupment of overpayments. The Health Care Education Reconciliation Act of 2010 (Pub.L.111-152) amended provision of Pub. L. 111-148 (Patient Protection and Affordable Care Act) to demand that providers and suppliers return any overpayments within the time frame stipulated above. Plus, the provider/supplier must inform the CMS in writing of the reason for the overpayment. In addition to providers and suppliers, this stipulation applies to Managed Care Organizations, Medicare Advantage Organizations, and Part D Plan sponsors, but not beneficiaries. Initially, the regulations will be amended to affect Part A and B providers and suppliers.  For more see http://s3.amazonaws.com/public-inspection.federalregister.gov/2012-03642.pdf

CMS: RACs to Conduct Prepayment Demonstration Project

By: Barbara Aubry

On November 15, 2011, CMS has announced it intends to have RACs, MACs and CERTS conduct prepayment reviews in states with “historically high rates of improper payments” based on prior audits.  In this category, seven states have been selected for the demonstration: FL, CA, MI, TX, NY, LA and IL. Four states with high volumes of claims for short inpatient stays are also included in the demonstration: PA, OH, NC and MO; adding up to eleven states in total. According to CMS, the goal is to “help lower the error rate by preventing improper payments rather than the traditional ‘pay and chase’ methods of looking for improper payments after they have been made.” The demonstration begins January 1, 2012, and is expected to last for three years.  The project has two areas of focus: the eventual preauthorization of certain DME (temporarily on hold – click here for more) and the second is the ability for hospitals to resubmit claims for 90 percent of Part B charges on an inappropriate short stay.

CMS and OIG Announce New Compliance Programs

By: Barbara Aubry

On November 16, 2011 CMS announced new demonstration projects to help curb fraud and abuse. You may recall that in 2010 President Obama announced the goal of reducing overall payment errors by $50 billion, cutting the fee-for-service error rate by 50% and recovering $2 billion in improper Medicare and Medicaid payments.

As of January 1, 2012 CMS intends to begin demonstration projects to safeguard the Medicare trust fund by increasing the Recovery Audit Prepayment Reviews, prior authorization for specific DME and a continued focus on Part A to Part B rebilling.

AMA Vows to Fight ICD-10

By: Barbara Aubry

During its semi-annual policy making sessions, the American Medical Association released its resolutions to stop the implementation of the ICD-10 CM (diagnosis) and PCS (procedure codes) implementation.  CMS responded that it does not intend to alter its ICD-10 migration go-live date of October 2013. Specifically, the AMA resolved to “vigorously work to stop the implementation of ICD-10 and reduce its unnecessary and significant burdens on the practice of medicine.” It further resolved that it will “do everything possible to let the physicians of America know the AMA is fighting…on their behalf.” And finally, it announced its intention to work with other national and state medical and informatics associations to determine an appropriate replacement for ICD-9.

What? Are they serious?

God Bless the OIG

By: Barbara Aubry

Last week I read a report from the Office of Inspector General (OIG) to Donald Berwick, MD about two Outpatient Prospective Payment System (OPPS) audits they completed on Medicare contractors. The first was a review of Palmetto GBA (Jurisdiction 11) for dates of service January 1, 2006 through June 30, 2009.

And the second report to Dr. Berwick concerned an audit they performed on National Government Services (NGS), the Jurisdiction 13 MAC for the same dates of service.

The bottom line; both Palmetto and NGS made incorrect overpayments for OPPS services.

Medical Necessity and Cloning

By: Barbara Aubry

I recently read a great article from Report on Medicare Compliance by Nina Youngstrom titled “Medicare Watchdogs, Compliance Officers Investigate ‘Carry Forward’” that brought back memories of my days as a Utilization Review nurse. As the article reminds us, CMS has no hard and fast national position on the use of electronic (or manual for that matter) medical record short cuts such as templates or the ubiquitous cut-and-paste transfer of patient data from one encounter to the next. Click here to learn more. While a definite time-saver, this habit does present compliance issues that payers are beginning to notice.  And some are going so far as to wonder — if your documentation does not change from one date of service to the next — are those visits really medically necessary?

ICD -10 and Mobile Phones

By: Barbara Aubry

Over the last few weeks I’ve had the pleasure of communicating with industry colleagues. We’ve been discussing documentation or lack thereof in different forms and for different reasons. What should be documented in the clinical record regarding medical necessity determinations? Are records adequately documented now to code in ICD-9 and what will happen when we move to ICD-10 absent documentation improvement? All contributors in the discussion from physicians to coders agree on a single premise – we need to improve documentation, and we need to do it now.  In theory, if we can’t get the first step in the process right how can we expect to produce accurately coded and billed claims in ICD-10?

Medical Necessity: More Than a CPT and ICD Code Pair

By: Barbara Aubry

In real estate, value is determined by three things — location, location and location. In my opinion, a similar adage should be created for determining the value of medical services. Medical necessity is based on three things – documentation, documentation and documentation. It’s more than pairing a CPT and ICD code that will pass your claim scrubber. It’s even more than making a patient feel better.

On July 28, 2011, Daniel R. Levinson, Inspector General, U.S. Department of Health and Human Services testified that “medically unnecessary services are particularly concerning as beneficiaries may be subjected to tests and treatments that serve no purpose and may even cause harm.”