If you receive a letter from a Medicare recovery audit contractor (RAC) regarding overpayment, don’t panic! You may think you only have two options: pay up or launch an appeal. There is another option, however, if you move fast (before a formal appeals process starts) and are certain the RAC is mistaken about the overpayments.
According to David M. Vaughn, JD, CPC, of Vaughn & Associates, LLC, “42 CFR 405.374 allows the provider at least 15 days for an informal rebuttal before the formal appeal process starts. The typical RAC letter will state that you have 15 days to informally respond prior to the time the RAC submits its results to the Medicare administrative contractor (MAC), who then issues the formal demand letter. So the first step in the process is to quickly figure out why the RAC is incorrect, and advise it within 15 days; and if you are correct, the RAC will correct the audit mistakes and reissue a revised letter to you and the MAC.”
Section 405.374 “Opportunity for rebuttal,” states:
(a) General rule. If prior notice of the suspension of payment, offset, or recoupment is given under § 405.372 or § 405.373, the Medicare contractor must give the provider or supplier an opportunity, before the suspension, offset, or recoupment takes effect, to submit any statement (to include any pertinent information) as to why it should not be put into effect on the date specified in the notice. Except as provided in paragraph (b) of this section, the provider or supplier has at least 15 days following the date of notification to submit the statement.
(b) Exception. The Medicare contractor may for cause:
(1) Impose a shorter period for rebuttal; or
(2) Extend the time within which the statement must be submitted.
Vaughn, who has defended several RAC audits, said, “All the ones I’ve defended did have the 15 day limit in their letter. I have used it successfully once, where the RAC made a mistake denying over $100,000 in services as ‘services not rendered’ when the real issue was that the incident-to rules weren’t followed, but the services should have been allowed in the name of the NP. They reversed that component of the audit before submitting the demand letter to the MAC. In that case, I actually called them and got an extension of the 15 days, and they granted it. I then submitted our position in writing, and they agreed.”
“RACs are fairly inaccurate—unlike the ZPICs [zone program integrity contractors], which are much more accurate in my experience—so I think the rebuttal process can be a good tool with the RACs, not ZPICs,” according to Vaughn.
Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, founding partner of Miscoe Health Law, LLC, said that in his experience, mostly with ZPICs, “I would generally use rebuttal ONLY when the client intended to pay, but there was concern about blind acceptance of the audit result leading to allegations of knowledge of the error down the road.” Miscoe’s bottom line is:
- “Providers should weigh (with the advice of counsel) the expense vs. the benefits of attempting a rebuttal rather than a formal appeal. Engaging in this process is more likely to be successful in response to a RAC audit with obvious errors.
- In cases where the provider chooses not to appeal when faced with a minimal refund demand (as in a probe audit), the rebuttal process is a mechanism for putting your objections to the audit findings on record. That way, mere payment cannot be construed later as agreement (and knowledge as in False Claims Act (FCA) context) with the audit result.”
March 26th, 2013
It is possible that within a few years, if your providers are challenged with a difficult or unusual case, an email to a major clinic such as the Mayo or Cleveland will help resolve the patient’s woes. Facilities and medical groups affiliated with these centers are already reaping benefits.
An article in The Atlantic Monthly highlights efforts by the Rochester, Minn.-based Mayo to affiliate with entities across the country. The well-known clinic has begun affiliating with hospitals and health systems, expanding its reach while acting as a resource for physicians faced with medical cases not seen in the area. Mayo, like Cleveland, Danville, Pa.’s Geisinger Health Systems, and M.D. Anderson Cancer Center in Texas, is looking nationwide as part of this strategy. Mayo has proven the most aggressive pursuer of affiliates so far.
The affiliation benefits the provider, who can consult physicians at the Mayo on cases rare in smaller facilities, but often seen at Mayo and the Mayo Clinic, which seeks to expand beyond its medical centers in Minnesota, Arizona, and Florida and its chain of community clinics and hospitals in Wisconsin and Minnesota.
“Our model has been that the patients come to us,” said Dr. John Noseworthy, Mayo’s president and chief executive officer, at a February press conference. “Increasingly, going forward … we also wish to extend the reach of the Mayo Clinic, taking our knowledge, taking our experience, and sharing it with others.”
Physician Michael Brown said in The Atlantic article, “For a bread and butter obstetrician like me, it’s amazing to feel that the Mayo Clinic has your back.”
How the Model Works
Affiliated physicians can consult electronically with Mayo specialists about patients who are difficult to diagnose or treat within 24 hours. The proprietary electronic system also allows physicians to speak directly with Mayo physicians. These patients go to the front of the line ahead of others seeking Mayo consultations. However, the goal isn’t to increase consultations or referrals, Mayo told The Atlantic.
“They haven’t been aggressive about pushing referrals,” said Brian Turney, chief executive of Kingman Regional, which has brought six Mayo-trained radiologists onto its staff since announcing the affiliation last October.
A nearby health system is sending fewer patients to Mayo’s campus than before the affiliation, it claims, pointing out that the affiliation allows the health system to bring the resources of the Mayo to it. Affiliates also get access to AskMayoExpert, an extensive Mayo-created database that includes so-called “care pathways,” spelling out what should be done, when, and how, for patients with various medical conditions. And they receive consulting services from Mayo experts on matters such as improving patient satisfaction, creating better systems to monitor quality care, or building medical teams that collectively manage patients. Although affiliates can advertise the relationship, they can’t claim they’re officially part of the Mayo Clinic.
In exchange, “We would hope that they will think of us if a complex patient needs to leave the community,” Dr. David Hayes, medical director of the Mayo Clinic Care Network, told The Atlantic. Mayo staff carefully vet candidates to determine if they’re financially stable, well run, and if their values and medical culture are compatible.
Current members of the Mayo Clinic Care Network are NCH Healthcare System of Naples, Fla.; Dartmouth-Hitchcock of Lebanon, N.H.; Altru Health System of Grand Forks, N.D.; Arizona State University Health Services of Tempe, Ariz.; Heartland Health of St. Joseph, Mo.; Kingman Regional Medical Center of Kingman, Ariz.; and Sparrow Health System of Lansing, Mich.
September 18th, 2012
Stage 2 Meaningful Use guidelines become effective November 5. To take full advantage of financial incentives available to your practice, knowing what is expected will help.
The Centers for Medicare & Medicaid Services (CMS) announced a final rule after Labor Day specifying the Stage 2 criteria set for eligible professionals, eligible hospitals, and critical access hospitals (CAH) to quality for Medicare and Medicaid electronic health record (EHR) incentive payments. The rule also outlines payment adjustments made if program participants fail to meaningfully use EHR technology. However, the new rules provide a flexible reporting period for 2014 so providers will have sufficient time to adopt or upgrade to the latest technology available in 2014.
CMS said Meaningful Use, which is divided into three stages, affects one out of every five eligible health care professionals.
- Stage 1 sets the basic functionalities electronic health records must include, such as capturing data electronically and providing patients with electronic copies of health information.
- Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information.
- Stage 3 will continue to expand meaningful use objectives to improve health care outcomes.
Remember that if your practice is not a facility, you must meet the measurements or quality for exclusion to 17 core objectives and three to six menu objectives. (If you are a hospital or critical access hospital (CAH), you must meet 16, with three to six menu items.) However, if you are using “2011 Edition Certified EHR Technology,” you may use it until 2014. Some new criteria include:
- Patient Engagement. CMS proposed two new core objectives providing patients online access to health information and secure messaging between patient and provider with measures that require patients to take specific actions for a provider to achieve meaningful use and receive an EHR incentive payment. For both objectives, the threshold was set at 10 percent of patients. While providers expressed concern, CMS is finalizing the proposed measures with reduced thresholds of 5 percent for both objectives. In addition, CMS introduced exclusions based on availability of broadband in a provider’s practice area.
- Electronic Exchange of Summary of Care Documents. To spur provider commitment to electronic exchange, CMS had initially proposed two ambitious measures for this objective in Stage 2. The first measure required that a provider send a summary of care record for more than 50 percent of transitions of care and referrals. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals. CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR.
Prepare, too, for clinical quality measure (CQM) guidelines. The rule finalizes that providers must report on nine out of 64 CQMs. All providers must select CQMS from at least three of the six key health care policy domains from the Department of Health & Human Services (HHS) national quality strategy:
- Patient and family engagement
- Patient safety
- Care coordination
- Population and public health
- Efficient use of health care resources
- Clinical processes/effectiveness
For more information about this and hardship exceptions, review the Final Rule, published in the Federal Register Sept. 4.
September 12th, 2012
Effective immediately, the Centers for Medicare & Medicaid Services (CMS) is removing OP-16 Troponin results for emergency department acute myocardial infarction (AMI) patients or chest pain patients (with probable cardiac chest pain) received within 60 minutes of arrival from its hospital Outpatient Quality Reporting (OQR) program. (more…)
September 10th, 2012
The Centers for Medicare & Medicaid Services (CMS) issued, Aug. 1, a final rule for 2013 payment policies for inpatient stays at general acute care and long-term care hospitals (LTCH). The new rule includes elements of the Affordable Care Act (ACA) hospital value-based purchasing and hospital re-admissions reduction programs. The rule also includes new efforts to tie Medicare payments to quality health care across the delivery system, with new quality reporting measures for hospitals in 2015 and 2016, new measures for LTCHs in 2016, and new quality reporting programs for psychiatric and cancer hospitals. (more…)
August 9th, 2012