National Healthcare Compliance Audioconference: Medicare RAC Audit Update Don May
description
Transcript of National Healthcare Compliance Audioconference: Medicare RAC Audit Update Don May
1
National Healthcare Compliance Audioconference:
Medicare RAC Audit Update
Don MayAmerican Hospital Association
May 13, 2008
2
CMS ViewCMS ViewFY 2007 RAC Performance: FY 2007 RAC Performance:
Overpayments Collected: $357.2mLess Underpayments Repaid: - ($14.3m)
Less $ Overturned on Appeal:
- ($17.8m)
Less Costs to Run Demo: - ($77.7m)
BACK TO TRUST FUNDS $247.4 m
$$??
3
• Hospitals strive for accuracy in service, billing, and coding
• Hospitals support program integrity efforts
• Lot’s of overlap by auditors• RACs’ bad behavior unacceptable
4
Medicare coding problems and providing unnecessary care (wrong setting) were
the key target areas of RACs
SOURCE: Self-reported by RACs
17%Other
9% No/Insufficient Documentation
32%Medically
Unnecessary
42%Incorrect Coding
??
5
43.4%
Percent of Hospital FY 2007 Revenue Impacted by RACs
0%
10%
20%
30%
40%
50%
60%
70%
80%
No Offsets 0% to 2.5% 2.5% to 5% 5% to 10% > 10%
New York
Florida
California
60.4%
23.2%
31.8%
5.0% 1.4% 1.4%
70.4%
2.0% 0.5%3.9%
25.0%
5.2% 7.0%
18.2%
SOURCE: CMS 2007 RAC Status Report
6
CMS Has Responded to Some Concerns
RAC Program Improvements• No Contingency Fee when Denial is Overturned at
Any Level of Appeal • Required to Have a Medical Director• 3-year Look-back Period for Review • No claims with a payment date prior to October 1,
2007 will be reviewed, regardless of the actual start date for the RAC in a state.
• Use of Staggered Expansion of RACs• Limits on the Number of Medical Records a RAC can
Request per Month• Requirement for a Web-based Application by January
1, 2010 • No funds recouped during first 2 stages of appeals
process, IF denial appealed within 30 days
7
• Work with CMS for more RAC program changes
• Push Congress for legislative relief– Advocacy – STOP and Fix-it– Capps-Nunes legislation (HR 4105)
• Member Education– Collaboration and education with state
hospital associations– Member advisories and education
sessions – RACTrac: Collect data and examples of
egregious behavior
8
The Medicare Recovery Audit Contractor Program Moratorium Act of 2007
HR 4105Rep. Lois Capps (D-CA) Rep. Devin Nunes (R-CA)
• 77 co-sponsors• 1-year Moratorium• CMS Report• GAO Study
9
STOP and Fix-itSTOP and Fix-it• Slow down• Reduce or remove contingency
method of payment• Exclude medical necessity from
RAC review• Reduce look-back to 12 months• Centralized electronic tracking
platform of RAC denials and appeals • Exemption from “timely billing” rules• Improved CMS management and
transparency of RAC program• Bigger focus on UNDERpayments
10
• Establish internal RAC team • Interdisciplinary Team: Coders, Finance, Clinical, Utilization Review,
Case Management• Identify RAC point of contact for internal and external
RAC communications• Develop a central tracking mechanism for all RAC
correspondence• Incoming and Outgoing
• Conduct a self audit to identify potential problems• Participate in RAC trainings