HCPro.com - Revenue Cycle - DO NOT USE Top Stories

Accepting applications for program coordinator award

Tue, 17 Nov 2009 16:51:00 GMT

HCPro, Inc. is excited to announce the Professionalism in GME Program Management Award.

The award recognizes residency and fellowship program coordinators whose leadership, teamwork, and professionalism embody an image of excellence and who make a difference in improving resident and fellow training, training program management, and the training program environment. It celebrates those who embody a positive image of the program coordinator that elevates the profession as a whole.

Nominate yourself or a coordinator colleague. Visit the award Web site for more information and to submit a nomination.

Winners will be honored at an award ceremony during the 5th Annual Residency Program Management Workshop in 2010 (details to be announced) and profiled in HCPro’s national residency program publications, including Residency Program Alert and www.ResidencyManager.com.

**If the links above do not work, try typing www.hcpro.com/GMEaward into your Web browser. If you still cannot access the Web site, e-mail me at jmccoy@hcpro.com.

Note: More on deductibles and coinsurance

Tue, 17 Nov 2009 05:00:00 GMT

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS recently published the Part A deductible and coinsurance and Part B deductible amounts for CY 2010. For most covered inpatient stays, as well as covered outpatient services, Medicare does not pay the entire Medicare allowable for those stays or outpatient services. Beneficiaries generally are responsible for a portion of the Medicare allowable in the form of deductibles and/or coinsurance.

Under Part A, Medicare beneficiaries are entitled to 90 regular benefit days per benefit period. Regular benefit days renew whenever a new benefit period begins. That is, a patient once again has 90 covered inpatient days every time a new benefit period begins. Medicare beneficiaries are also entitled to 60 lifetime reserve days, which may be used after regular benefit days for that benefit period have been exhausted. Lifetime reserve days do not renew. Once used, they are gone forever.

Click over to the MedicareMentor Blog to read more.

Providers report first RAC denials in Florida, South Carolina

Tue, 17 Nov 2009 05:00:00 GMT

Healthcare providers in several states received their first RAC denials. Connolly Healthcare, the Region C RAC for Florida, South Carolina, and several other states, has been behind many of them.

One hospital in South Carolina reports having three claims denied. However, learning of those denials did not go smoothly. The hospital received a call in late October from Connolly regarding a denial letter the hospital never received. The RAC sent the original denial letter in early August, and although it was addressed to the hospital, it apparently had no specific contact person listed, and the hospital never received it. The hospital had provided Connolly with the name of the contact person for their facility months prior via the form Connolly provided on its Web site, according to a hospital employee.

“Connolly acknowledged that the absence of a contact person on the letter was their error and they are working to correct it,” she said.

In the meantime, the RAC faxed a copy of the denial letter to the hospital. The total take back was less than $200, but it has given the hospital a chance to test its RAC tracking system, which is reportedly working well thus far.

Another small contract rehab company that contracts with facilities across seven states, mainly in the southeast, also reported receiving RAC denials. Three of its facilities, all skilled nursing facilities averaging 120 beds, have now received demand letters, according to the Florida-based provider.

“A majority of what we are seeing is recoupment of service-based codes billed in error more than once per day, mainly speech therapy (ST) service-based codes,” according to a provider employee. “We have also received two that included recoupment for the ST codes of 92610 and 92526 billed on the same day, which we have disputed and reported this issue to the American Speech-Language-Hearing Association.”

The provider is appealing the denials where the RAC is seeking recoupment of the ST codes 92610 and 92526 billed on the same day.

“We have a dedicated denials and appeals department and we have been handling these very efficiently and effectively,” she said. The provider has had no problems so far with the appeals it has submitted.

The provider also noticed that the demand letters seem to be taking approximately two weeks to arrive, so timing is of the essence, particularly if the provider is going to respond with appeals.

The provider also notes that it has used the denials as a guide for its internal auditing. Staff members are now going back to look for trends or patterns related to those denials.

HealthDataInsights posts several new RAC DME claim issues

Thu, 12 Nov 2009 05:00:00 GMT

HealthDataInsights (HDI) has added multiple new RAC issues to their CMS-approved list in late October and early November. The new issues are approved for RAC audits in Region D for DME claims.

According to the HDI Web site, the new issues and their descriptions are as follows:

PEN supplies more than one time a day. The description or the billing guidelines state parenteral/enteral nutrition codes are allowed once a day.
Infusion pump denied/Accessories and drug codes should be denied. When the infusion pump is denied, then the infusion accessories and infusion drug codes are also denied.

To stay on top of the latest RAC-approved issues in your state, visit the “Tools” section of the Revenue Cycle Institute Web site and download the updated chart at the top of the page.

Could RAC mass adjustment changes mean increase in automatic audits?

Thu, 12 Nov 2009 05:00:00 GMT

Providers who believe their RAC denials will be limited to 200 every 45 days (corresponding with the medical record request limits) may be in for a surprise. Those limits apply only to complex audits, but no such limits exist for the number of automatic reviews RACs can perform.

“RACs can do as many [automated reviews] as they want. I think it is in people’s heads that they can look at only 200 at any one time, but that’s really not true,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

In fact, recent changes to the RAC process for handling mass quantities of recoupments from automatic reviews may even make it easier for RACs to increase their auditing capabilities—meaning the potential for even more denials for providers.

In the past few weeks CMS released three transmittals (R561OTN, R571OTN and R573OTN) detailing several technical changes to “enhance” the RAC mass adjustment process. Essentially, the changes improve the process for the RACs by automating what used to be much more labor-intensive process of initiating mass adjustments of similar claim and/or service types.

“CMS is going to allow RACs to now upload entire files to the intermediary to make mass adjustments, and this is going to make automated denials much quicker for RACs,”

Hoy says. “And whenever you go from manual to automated, you’re going to have a huge increase in efficiency. The changes mean a hospital could get literally thousands of claims denied in one day.”

CMS first came out with a RAC-oriented mass adjustment process in 2007, but the changes should make it easier for the RACs. “Basically they can just run reports now,” Hoy explains.

And if the back-end work involved in processing mass quantities of automatic denials decreases for the RACs, does it mean an increase in their ability to further audit healthcare providers?

We may have to wait until April 5, 2010, when the changes take effect, to find out.

Nation's largest nursing home pharmacy to pay $98 million for kickback schemes

Wed, 11 Nov 2009 05:00:00 GMT

The nation’s largest nursing home pharmacy, Omnicare Inc., will pay $98 million to resolve allegations that it violated the False Claims Act and participated in several kickback schemes, according to a Department of Justice (DOJ) press release. Drug manufacturer, IVAX Pharmaceuticals, will pay $14 million to resolve allegations that it engaged in kickback schemes with Omnicare.

According to the DOJ, Omnicare allegedly solicited and received kickbacks from drug manufacturer, Johnson & Johnson, in exchange for prescribing Risperdal, an antipsychotic drug, to nursing home patients. Johnson & Johnson allegedly disguised the kickbacks as data purchase fees, educational grants, and fees to attend Omnicare meetings. The DOJ reports that Omnicare also paid kickbacks to nursing homes in order to induce the homes to refer patients to Omnicare.

Omnicare also received $8 million in kickbacks from IVAX in exchange for purchasing $50 million in drugs from IVAX.

Approximately $68.5 million of the settlement will go to the United States and $43.5 million will cover Medicaid program claims by participating states.

Note: Signature for Laboratory Tests, Clarification in the MPFS Final Rule

Tue, 10 Nov 2009 05:00:00 GMT

This week, I would like to review a “clarification” regarding physician signatures on orders for clinical diagnostic testing that came out in the Final Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for 2010. Although this publication is hospital-directed and we do not normally report on physician fee schedule issues, this “clarification” could affect hospital policies on obtaining signatures for the laboratory services they provide.

Click over to the MedicareMentor Blog to read more.

Small healthcare entities need Red Flags the most

Wed, 04 Nov 2009 19:29:00 GMT

Small healthcare entities are more likely to have patients who are victims of identity theft. So why exclude them from complying with a mandatory identity theft prevention program?

Randy Berry, B.A., C.P.A., financial leader and Red Flags Rule compliance expert with Columbus Healthcare & Safety Consultants in Columbus, OH, asks that very question.

“The biggest concern that I have is … the smaller the practice, the less internal controls they have and the more apt the smaller practices are to have identity theft," says Berry, author of the Red Flag Manual and Training CD Package. "The most critical thing is protecting patients' identity. It's not about the doctor. It's about the patients' financial identity. The lobbyists forgot that this is not about practices; it's about patients and their customer's financial information."

The House of Representatives unanimously passed a bill October 22 that would exempt a healthcare practice with 20 or fewer employees from the FTC's identity theft Red Flags Rule requirement. The Senate is now considering the bill.

The Red Flags Rule, which will be enforced starting June 1, 2010, requires healthcare entities considered to be "creditors" to implement an identity theft prevention program.

Texas Hospital group pays U.S. $27.5 million in false claims settlement

Wed, 04 Nov 2009 05:00:00 GMT

A Texas hospital group will pay the United States $27.5 million to resolve allegations that it violated the False Claims Act, the Anti-Kickback Statute, and the Physician Self-Referral Law (Stark Law) between 1999 and 2006, according to a Department of Justice (DOJ) press release.

McAllen Hospitals L.P., doing business as South Texas Health System, subsidiary of Universal Health Services Inc., violated all three regulations by paying illegal compensation to physicians in order to persuade them to refer patients within the hospital group.

Under the Stark Law, Medicare providers are prohibited from billing Medicare for referrals from doctors with whom the providers have a financial relationship. The hospital group distributed payments to the physicians through a series of sham contracts, including medical directorships and lease agreements.

The federal government will receive approximately $25.2 million of the settlement and the Texas Medicaid program will receive $2.3 million for the false claims submitted to the program. Bruce Moilan, a former employee of the defendants, raised the case using the False Claims Act’s qui tam provision. Moilan will receive a $5.5 million share of the settlement.

Note: CMS issues 2010 final rule for ambulatory surgery centers and most hospital outpatient departments

Tue, 03 Nov 2009 05:00:00 GMT

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS has released a display copy of the outpatient prospective payment system (OPPS) final rule for 2010, which also includes the 2010 changes to the rules for ambulatory surgery centers (ASCs). This final rule will be published in the Federal Register on November 20. In terms of reimbursement, OPPS hospitals that meet quality indicator reporting requirements for 2010 are entitled to the “full update,” which will result in a 2.1% increase in their payments for 2010. Those OPPS hospitals that do not meet their quality indicator reporting requirements will be subject to a reduced update of 0.1% in 2010. ASCs, on the other hand, will receive a 1.2% inflation update beginning January 1, 2010.

Among the most anticipated changes in the OPPS final rule are the so-called “incident to” a physician’s services requirements. Most nonphysician outpatient therapeutic services that are provided by hospitals or critical access hospitals (CAHs) are only covered if they are provided “incident to” the services of a physician or another specified nonphysician practitioner.

Click over to the MedicareMentor Blog to read more.

Region B and D RACs post new issues, all states now approved for audits

Thu, 29 Oct 2009 05:00:00 GMT

CGI, the RAC for Region B, has posted three new issues for review in Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin. This means CMS has now approved issues for RAC auditing in all states.

The new issues approved for physician and outpatient hospital claim review in these states are:

For more information on these and other issues approved for Region B states, visit the CGI Web site.

In addition, CMS has approved a new issue for DME provider audits in Region D—Knee orthotic bundling. “There are Knee orthotic addition codes that cannot be billed separately due to the fact that they are bundled with the base knee orthotic code or that the addition code is not medically necessary when billed in conjunction with a specific knee orthotic base code,” according to HDI, the Region D RAC.

For more information, visit the HDI Web site.

Three pharmacies and their employees indicted on Medicaid fraud charges

Wed, 28 Oct 2009 05:00:00 GMT

New Jersey Attorney General Anne Milgram announced the indictments of four pharmacists, three pharmacy technicians, and three pharmacies on charges to conspiracy to defraud Medicaid of over $2.3 million, according to an Attorney General’s Office press release.

The three Newark area pharmacies, their owners, and employees allegedly paid cash to any patient who agreed not to take their medicine. Those prescriptions were then used to fraudulently bill Medicaid for thousands of dollars, the AG said. In other instances, medicines were dispensed to patients, then sold back to the pharmacy for a share of the Medicaid reimbursement, according to the AG.

All 10 defendants are charged with conspiracy, healthcare claims fraud, and Medicaid fraud.

Note: CMS Announces the 2010 Medicare Premiums and Deductibles

Tue, 27 Oct 2009 05:06:00 GMT

Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS recently announced the CY2010 Medicare Part A deductible for inpatient hospital services. When a patient is admitted as an inpatient, the deductible will increase from $1,068 in 2009 to $1,100 in 2010. In addition, beneficiaries will pay an additional daily coinsurance of $275 for days 61 through 90 and $550 for lifetime reserve days. For 2009, the corresponding amounts are $267 and $534, respectively.

Click over to the MedicareMentor Blog to read more.

Boston man to serve 10 years in prison for several counts of healthcare and insurance fraud

Wed, 21 Oct 2009 05:00:00 GMT

Former health clinics owner, Tu Quy Mai, will serve 10 years in prison for committing several acts of mail fraud and submitting false claims, according to a Department of Justice release. Mai, 59, pled guilty on December 10, 2008 and will pay over $3.7 million in restitution and a $5,400 special assessment.

Mai established and operated several clinics around the Boston area where he would submit false and fraudulent medical and physical therapy billing claims for staged auto accidents. Mai would pay people to stage accidents, while ordering workers to prepare false records, including evaluation reports and notes of alleged treatments for the “injured,” when neither were performed.

From 2000 through 2006, Mai often changed the name of his clinics and billing companies and told other coworkers to maintain themselves as owners. During that time, insurance companies paid more than $4 million in claims submitted by Mai’s clinics and billing companies.

Note: Implementation of permanent and nationwide RAC Program

Tue, 20 Oct 2009 05:00:00 GMT

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

Now that CMS has implemented a permanent and nationwide Recovery Audit Contractor (RAC) Program, as authorized by the Tax Relief and Healthcare Act of 2006, hospitals need to keep themselves informed about the issues that have been approved for review in their region. Going forward, the four regional RACs will continue to review claims on a post-payment basis, using standard Medicare policies. They will be limited, however, to a three-year look-back period, with no review of claims paid prior to October 1, 2007.

Click over to the MedicareMentor Blog to read more.

Q/A: Does physician documentation in written reports constitute an official order?

Fri, 16 Oct 2009 05:52:00 GMT

Q: We don’t have the usual written orders for several tests. However, physicians dictate or document in their reports that they or someone else performed the tests. Does this constitute an order for billing purposes, especially if a physician performs the test?

For example:

Hemoccult—The ER physician performs this during the exam, but doesn't write an order for it on the order sheet
Parathormone—The surgeon dictates the following in the operative report: “Did baseline, 10 minutes after removal, 15 minutes after removal, and 25 minutes after removal.”

Physicians perform point of care testing in the surgery suite. There is an order sheet and the nurse in the operating room is supposed to record all tests. If the nurse misses the test on that sheet, is the dictated statement that the physician performed the test equivalent to an order?

A: A physician’s order is necessary to ensure that the physician actually requested the service provided. It is a check-and-balance system. Without documentation of an order, providers cannot bill because they don’t have legal authority to order or provide the service. Often, a physician writes an order and another clinician performs the necessary task. A separate order is unnecessary when physicians perform the services, for example in the OR.

Tip: Appropriately report units in excess of MUE

Fri, 16 Oct 2009 05:49:00 GMT

In FAQ 8736, CMS instructs hospitals how to report units in excess of the medically unlikely edits (MUE) limits. Hospitals should place the same code on separate claim lines, with an appropriate modifier, so the number of units on each line is within the MUE limit.

Hospitals can use the following modifiers, according to the FAQ:

-76 (repeat procedure by same physician)
-77 (repeat procedure by another physician)
Anatomic modifiers (e.g., -RT, -LT, -F1, -F2)
-91 (repeat clinical diagnostic laboratory test)
-59 (distinct procedural service) only if no other modifier describes the service

In prior guidance (FAQ 8735), CMS said that contractors should apply MUE limits against each line of a claim, rather than the entire claim. Therefore, if a hospital reports a HCPCS or CPT code on more than one line of a claim by using modifiers, the contractors should separately adjudicate each line with that code against the MUE, according to CMS.

This tip was adapted from the article “Two years later, MUEs are still a puzzle” in the October issue of Briefings on APCs.

AHA RAC Program Update answers provider questions

Thu, 15 Oct 2009 05:00:00 GMT

As of September 18, all four RACs were conducting automated audits, according to an October 6 American Hospital Association (AHA) RAC program update. But only 16 of the 23 audits underway were on hospital outpatient claims, according to the AHA. (The others were therefore on physician and durable medical equipment claims.)

So unless your hospital is so very unlucky to have been selected as one of the first for an audit, chances are you still have time to make a few necessary tweaks and run a few tests on your RAC processes to help ensure you're ready when RACs do begin auditing your facility.

The AHA also updated providers on the arrival of additional types of RAC audits (e.g., DRG validation and medical necessity). RACs have already requested the ability to audit for more than 100 different issues, according to the AHA. Some of these include code and DRG validation reviews, which CMS has not yet approved, choosing instead to begin solely with automated audits involving no need for medical record review.

And while DRG and coding reviews could begin as soon as November, the AHA says CMS may delay the onset of medical necessity reviews so it can first establish a process that would give providers the ability to re-bill all eligible outpatient claims. CMS previously announced medical necessity reviews would begin in January 2010.

Click here to read more.

Ask the expert: What is the coordinator's role in screening applications?

Tue, 13 Oct 2009 18:21:00 GMT

The answer to this question is, “it depends.” The program director determines the process for reviewing applications. Program directors tend to pick one of the two following ways of reviewing applications:

Program directors utilize the program coordinator for the initial screening of applicants. The program director gives the coordinator a set of criteria that he or she will use to weed out those who do not meet minimum standards. Measures may include USMLE scores, receipt of medical school transcripts, and a set number of letters of recommendation. The program coordinator sends those applicants who make the cut on for a second review by the program director and/or application review committee.
Only the program director reviews all applications and determines which applicants will continue in the process.

Most program directors chose method 1, following up with discussions with the program coordinator to compare notes and impressions. During the second review of the applications, program directors, faculty, and coordinators thoroughly review the application and supporting documents to ensure compliance with program standards.

Send the applications to those reviews via ERAS. Faculty members will receive an e-mail from ERAS indicating that there are applications to review and provides a list of and a link to those applications.

This week’s question and answer are from The Complete Residency Program Management Guideby Ruth H. Nawotniak, MS, C-TAGME. Come see Ruth present at the 4th Annual Residency Program Management Workshop.