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
By Stephen C. Spain, MD, FAAFP, CPC
Angela “Annie” Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT
Editor’s note: Health care reform brings a number of new concepts to coding, billing, compliance, and practice management. The most far reaching—especially from an organizational point of view—are accountable care organizations (ACOs). Below is the first of three articles detailing why ACOs exist, how they work, and what affect they will have on us.
“Quality” and “value” have percolated to the top of health care payers’ concerns in recent years. Payer initiatives currently in development will have a substantial, pervasive, and dramatic impacts on virtually all AAPC members—and on patients and providers, as well. These initiatives focus on reducing unnecessary medical services to lower costs, and on identifying effective practice patterns.
The Challenge Ahead
The United States has the planet’s highest per capita health care expenditures. In 2010, we spent $2.6 trillion on health care (an amount equal to the entire economy of France). By 2019, an estimated 19 cents of every dollar will be spent on health care. Even as health care costs rise rapidly, significant federal regulations require additional expenditure and investment in health care infrastructure and technology (e.g., 5010, ICD-10-CM, administrative simplification, health care reform, health information exchanges (HIEs), etc). Many industry stakeholders and lawmakers are looking to payers and providers for ways to reduce costs, while ensuring efficacy and quality.
Nearly 32 million Americans do not have health insurance, which places an additional burden on health care reimbursement (the number of uninsured may change due to provisions in the Patient Protection and Affordable Care Act (ACA)). Patients without health insurance often do not seek care until they are very sick, which requires higher levels of care and higher utilization (e.g., emergency room (ER) visits, high-end radiological studies, etc.). For many uninsured, the ER—perhaps the most expensive setting in which to receive care—is the sole means of care. This requires states and hospitals to create uncompensated care pools for economically qualifying individuals. Uncompensated care pools lift health care costs through write-offs, increases in delivery costs, and higher premium rates.
For Payers, Quality Requires Value
As patients, when we consider the quality of our health care, we may think about how well trained our providers are, or how well equipped our local hospital is. But for those paying for health care on our behalf (employer-engaged insurance companies and the Centers for Medicare & Medicaid Services (CMS)), quality is defined as value received for the dollars spent. Payers don’t want to waste money on care that is medically unnecessary, care that is billed but not rendered, or treatments that are not proven.
In response, many payers have taken steps to implement quality-monitoring measures outside of the traditional-managed care model. For example, payers may create wellness programs and disease management programs to promote effective treatment methods and drive higher quality of care. Typically, payers will target high cost (often chronic) conditions such as diabetes, asthma, kidney disease, and heart failure, and create resources and tools to ensure that patients/members understand what quality care is and that participating providers are rendering the best care available. We know from quality measures that disease management is helping performance outcomes around many chronic conditions; however, health care costs continue to rise. Although helpful from a quality perspective, disease management is not enough to curb rising costs.
A New Response to Better Care and Contained Costs
Many payers (including CMS) are looking to evidence-based medicine (EBM), a widely applied principle of identifying treatments and practice habits that are proven to be beneficial, and are encouraging all practitioners to adopt these treatments and practice habits as a universal “gold standard” or “best practices.”
Before EBM, as new advances were made in medicine, it was assumed that the information would trickle down in meetings, seminars, and publications and that eventually all practitioners would become aware of the advances and adopt them. In reality, this model did not work. Providers trained one way generally stuck to what they knew, and were not eager to adopt new ways of practicing medicine.
In the 1990’s, the U.S. Preventive Health Services Task Force (USPSTF) was organized to review available medical data and make recommendations on which preventive services (Pap screening schedules, mammography screening, colonoscopies, etc.) should be applied to the entire population. Several medical groups, such as the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP), decided to build on the work of the task force and identify meaningful diagnostic and medical treatments for a variety of conditions. Where double-blinded, controlled studies support a recommendation, it would have the highest rating. Where medical study or evidence supporting a treatment or service is lacking, the item would have the lowest recommendation (or would not be recommended at all).
For example, at one time patients complaining of low energy were commonly given 1,000 units of B-12 as an injection. Studies eventually showed that there was no appreciable benefit to B-12 injections; therefore, B-12 injections for a “boost” are not recommended. (CMS stopped paying for B-12 injections with a fatigue diagnosis many years ago.)
Finding the Middle Ground
Patient expectations can lead to difficulties in implementing EBM recommendations. For example: Studies have shown that X-rays for an acute ankle sprain, in the absence of other risk factors, are not necessary. Several medical groups are on record as advising against X-rays in the initial evaluation of an acute ankle sprain. Following EBM guidelines, providers would not routinely order X-rays for the average patient with an acute ankle sprain.
But what happens when you go to the ER with an ankle sprain? Almost always, your ankle will be X-rayed (and almost always, the X-ray will be normal). The patient wants reassurance, and the ER doctor does not want to risk being sued on the remote chance that he might miss a fracture. Patient pressure and medical liability worries result in an unnecessary X-ray. Hundreds of thousands of such unnecessary treatments are rendered every year.
EBM will likely ensure medical care improves in both quality and value. But based on our example, EBM might not provide the care the patient wants or the physician is comfortable providing. The goal is to find the point of equilibrium, where our health care delivery system offers quality and value, as well as improved outcomes. It will take time, patient and provider education, and control of liability exposure to incorporate EBM into everyday medical care.
How Quality Measures Enhance Value
Payers (CMS in particular) have turned to the reporting of “quality measures,” most of which are based on a framework provided by EBM, to improve the value received for health care expenditures. Just after the turn of this century, CMS created the Premier Hospital Quality Improvement Project. It offered incentive payments to health professionals for reporting quality measures. You may have heard of this as “pay for performance” or “P4P.” The idea was to test the hypothesis that providers would report quality measures if they were paid extra to do so. It was a very successful experiment and proved that paying extra could produce the information CMS was seeking. From this experiment, the Physician Quality Reporting Initiative (PQRI) was born. PQRI has since become a permanent program, renamed the Physician Quality Reporting System (PQRS).
PQRS relies on “measures” tabulated over the course of a patient’s treatment. CMS realized it needed help from the medical community to determine what measures were important. EBM was used, wherever possible, as the guiding principle. The actual quality measures were developed by various medical organizations, such as the AMA, the American Gastroenterology Association (AGA), and others. These groups have put together several hundred measures that cover issues pertinent to most medical specialties and health care providers.
As an example of how a quality measure enhances value, consider the pneumonia vaccine. There is a quality measure for reporting that a patient is current on a pneumococcal pneumonia vaccine. If the patient is noted to be current at a visit, a code is added to the patient’s claim. If a provider finds that a patient is not current on his or her vaccine, he would administer the vaccine and report the code for that service, as well as a quality measure code for providing the vaccination. In this way, fewer patients will slip through the cracks and fewer Medicare patients will succumb to pneumococcal pneumonia. The value comes from the saved expenses of pneumonia treatment and hospitalization.
Quality Measure Reporting Requirements
Early indications are encouraging that reporting of quality measures will make providers less likely to overlook vaccinations (pneumonia, flu, tetanus, hepatitis B), preventive screenings (colonoscopy, Pap smear, mammography, PSA screening), counseling on health issues (smoking, obesity, fall risk), and treatments known to be effective for certain health conditions (statins for diabetes and heart disease, ACE inhibitors for congestive heart failure, aspirin for early myocardial infarction, anticoagulants for atrial fibrillation). A provider can pick several pertinent measures and report those for a year for the applicable patient encounters. The measures can be reported by either attaching a HCPCS Level II code to the claim for the encounter, submitting the information to a third-party registry, or through an electronic health record with PQRS reporting capability built in.
As an example, an endocrinologist may decide to report measures for diabetes. There are a number to choose from, but here are three that could be used:
- DM: Hgb A1C with poor control A1C >9.0%
- DM: LDL cholesterol controlled LDL-C < 100 mg/dl
- DM: High BP controlled BP < 140/90
Three measures are selected because three is the minimum number of quality measures a provider can report to be eligible for a bonus payment. To successfully report these parameters, the provider must address and report these items once in the course of the year—ideally, for every patient seen with a diabetes diagnosis. To qualify for an incentive payment, the measures must be reported for at least 80 percent of the eligible encounters.
There is no way to track progress with CMS over the course of the year, and many providers only learn after the year has ended if they met the criteria for a bonus payment. Currently, the bonus is 0.5 percent of the total Medicare payments received by the provider for the year. Unless there are changes, the bonus is phased out after 2014. Starting in 2015, penalties will apply for providers who do not report or who improperly report quality measures. The penalty in 2015 is 1.5 percent, which will increase to 2 percent in 2016, and will be applied against ALL Medicare payments.
CMS is not doing much with the quality measures data it is collecting, but that will change. Right now, most of the measures seem to be aimed at making sure that important treatment guidelines are not overlooked (e.g., blood pressure goals and aspirin for heart attack victims, and certain drugs for heart failure and diabetes care).
Measures’ reporting is almost certainly here to stay. Note that PQRS preceded and is separate from the ACA law, so PQRS is not likely to be affected by changes in the ACA interpretation or implementation.
Next month, we will feature part two of this three-part series: The (R)evolution of the ACO.
Dr. Spain, MD, FAAFP, CPC, has worked in family medicine for over 25 years. In 1998, he founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at email@example.com.
Annie Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT, is the director of 5010/ICD-10 communication, adoption, and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College, and a developer and member of AAPC’s ICD-10 training team. Ms. Boynton frequently speaks and writes about coding, including ICD-10 and 5010 implementation.
November 1st, 2012
Better Documentation + Better Compliance = Better Quality of Care
By Richard Skaff
Behavioral health has struggled with regulatory compliance, including documentation, billing and coding, treatment plans, and medical necessity. A “top down” approach to address shortcomings in behavioral health practice and diagnostics is the ultimate solution, but common sense and improved documentation will go a long way toward meeting compliance goals.
Document for Success
Documentation is an important aspect of compliance. To improve documentation, consider the following recommendations, courtesy of Anne Fisk and Mary Beth Thomas (“Regulatory Compliance Issues in Behavioral Health,” Journal for Healthcare Quality, 2003; (133))
- A chart entry must describe the service, as well as justify it.
- The progress note documentation must be legible, and must include:
o The date and duration of the session
o A description of the nature of the treatment service
o The patient’s response to the therapeutic intervention
o A plan
- Progress notes should contain recommendations for revisions in the treatment plan and an assessment of the patient’s response to treatment and progress in meeting the goals set forth in the original treatment plan.
- The medical record must specify the psychiatric components of the record.
- The content requirements for admission documentation are spelled out, as are the expectations for the treatment plan and progress notes.
To improve coding and billing in behavioral health, Fisk and Thomas further recommend:
- An accurate charge description master (CDM or chargemaster)
- Access only to appropriate codes for the level of the provider (e.g., codes for evaluation and management (E/M) are not provided to practitioners who are not qualified to use them)
- Clinical documentation must justify the code billed, including medical necessity
- Edits to ensure only payer-qualified clinicians are providing the services billed
- Accurate diagnoses recorded on claims
- An efficient process flow, from the service rendered to the bill submitted for payment
- Formal, regular communication and feedback loops between billing and clinical areas
- Education for billers that improves their ability to discriminate among clinical services and for clinicians that underscores the critical nature of their documentation and coding choices
Compliance Improves Care
Regulatory compliance is entangled with quality of care. To help behavior health providers merge the two, Fisk and Thomas recommend these best practices:
- Investigate and implement evidence-based practices wherever possible and reasonable.
- Abandon the notion that behavioral health should be perceived as “different.”
- Learn how other clinical areas in the system are handling compliance and share ideas.
- Recognize that treatment plans are helpful: Use them to direct treatment and to demonstrate that treatment’s efficacy. Begin with accurate, precise diagnostics and a clear description of symptoms and presenting problems. Include behavioral goals that are concrete, realistic, measurable, and meaningful to the patient. Make sure the plan is individualized to the patient, and update the treatment plan whenever a change is reasonable or the current treatment has not proven to be effective.
- Use electronic health records (EHRs).
- Educate everyone—including billing, clinical, and management staff—about regulations, payer expectations, compliance, and quality.
- Perform internal quality audits.
- Spread the word that compliance is not optional.
In an increasingly regulatory world, ethics and compliance are no longer optional. Ethics must be emphasized and prioritized over billing. A diagnosis should never be made just for billing purposes.
Compliance issues must be taken seriously as a means for self-improvement and progress. Fear of punishment and penalties should not be the main incentive to implement an effective compliance program.
The strategic components that would deter or reduce a prospective compliance conflict in behavioral health would entail:
- Establishing an honest relationship with payers
- Implementing prevention and detection strategies
- Admitting mistakes and implementing self-correction, education, and ongoing training for employees, as well as risk management, and transparency
Richard Skaff is former CEO of K&M Consulting Services. He is a practicing clinical psychologist and is board certified in psychopharmacology and forensic psychology.
May 1st, 2012
Under contract with the U.S. Department of Health & Human Services (HHS), the National Quality Forum (NQF) recently added four efficiency measures that “could be combined with quality metrics as part of the Medicare value-based purchasing plan set to start in 2015,” American Medical News reports.
Two of the new measures evaluate relative resource use for patients with asthma and chronic obstructive pulmonary disease (COPD), and a third looks at total costs for treating pneumonia. The final measure focuses on total costs for hip and knee replacement.
These four measures join four others, endorsed in January, which include metrics to examine resource use for patients with diabetes and cardiovascular conditions, and total resource use and total cost of care for all patients.
The central concept of value-based purchasing in health care is that buyers should hold providers accountable for both the cost and quality of care. Value-based purchasing seeks to reduce inappropriate care and to identify the best-performing providers. Ideally, those providers and health care systems that provide the best care at the best cost would be rewarded with greater numbers of patients.
By measuring resources used, rather than raw costs only, the NQF “is aiming to give apples-to-apples comparisons of physician efficiency that are not distorted by geographic price variations,” American Medical News continues.
The American Medical Association (AMA), among other groups, supports value-based purchasing initiatives, but has expressed concern whether such a system could be implemented without penalizing doctors who treat the most difficult cases.
April 27th, 2012