Analysis by Editor Tim Rowan
As we have emphasized over the last few months, too much attention is focused on the Recovery Audit Contractor program and too little on other contractors that have the power to reduce home care and hospice revenue today rather than on some unknown date in the future. For the contractors themselves, however, there is ample reason to pay attention. In fact, the reason so much time passed between demonstration and implementation is that several insurance companies and collection agencies whose bids to become RACs were not initially accepted sued to force CMS to reconsider their choices.
Obviously, the expectation is that these contracts will be quite lucrative for the contractors. But are they actually lucrative for Medicare and taxpayers? A quick look at the monies involved in the three-year RAC demonstration is quite revealing. It is clear why losing bidders put up such a fight. It is not clear, however, that Medicare and taxpayers will be significant winners. (more…)
File this one under “lesson learned…the hard way.” Incorporate it into your next staff training. This agency properly followed the government’s appeal procedure after receiving a notice of payment denial. Excerpts below show that the administrative law judge did not find the provider’s care lacking, just its paperwork. That is correct, it is not merely an old cliché. The job is still not finished until the paperwork is done…and submitted.
Some healthcare providers are concerned they may not know how to proceed if their organization is audited by a Recovery Audit Contractor (RAC) and receives a payment recoupment notice. Fortunately, there is a way to learn the RAC appeal process in advance and be completely prepared. (more…)
Since the inception of Medicare Fraud Strike Force operations in March 2007, the Strike Force has obtained indictments of more than 460 individuals and organizations that collectively have falsely billed the Medicare program for more than one billion dollars. In addition to the fraud hotbeds in Los Angeles, Houston, Detroit and — the one that dwarfs all three of them combined — Miami, the Department of Justice (DOJ) and the Department of Health and Human Services will soon target three additional cities, establishing strike force offices in Baton Rouge, Tampa and Brooklyn. Enforcement teams that include these two agencies plus the FBI and DEA are housed in strike force centers. (more…)
Attorney General Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius recently announced the creation of a new interagency effort, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to combat Medicare fraud. Holder and Sebelius also announced the expansion of Strike Force team operations to Detroit and Houston. Medicare Fraud Strike Forces, currently in operation in South Florida and Los Angeles, fight Medicare fraud on a targeted local level. (more…)
STATEMENT OF LANNY A. BREUER ASSISTANT ATTORNEY GENERAL CRIMINAL DIVISION UNITED STATES DEPARTMENT OF JUSTICE BEFORE THE UNITED STATES SENATE COMMITTEE ON THE JUDICIARY SUBCOMMITTEE ON CRIME AND DRUGS HEARING ENTITLED:
“CRIMINAL PROSECUTION AS A DETERRENT TO HEALTH CARE FRAUD”
PRESENTED MAY 20, 2009
Health care fraud enforcement has restored funds to the trust funds and protected our citizens from health care fraud schemes. The Department is committed to the ongoing success of the HCFAC program and will continue to marshal its resources, including those provided by the HCFAC program and its own discretionary funds, to ensure that federal health care dollars are properly expended. We are committed to prosecuting fraud and abuse in the Medicare and Medicaid programs and restoring the recovered proceeds to these programs. We look forward to working with Congress and this Committee in particular, through these efforts, to make health care available to those who have no such safety net. (more…)
“Clear as M.U.D.” presents actual stories of payment denials that appear on the surface to be difficult to explain. Fiscal Intermediaries and QICs are supposed to deny or recoup payments when a service to a patient appears to be a Medically Unbelievable Claim. On occasion, this can result in what we call a Medically Unbelievable Denial.
This Clear as M.U.D. saga is titled, “I’m OK. You’re OK. Your Patient, We’re Not So Sure About.”
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We may be rightly accused of harping on this theme a lot but it is important enough to revisit from time to time. Beware of those who would scare you into focusing on the government’s future revenue protection program, the Recovery Audit Contractors (RAC), so much that you lose sight of current programs. Some of them, such as the Zone Program Integrity Contractor (ZPIC) program, have the power to harm your business while the RACs are still decorating their new offices. (more…)
Keep an eye on the progress of Senate Bill 1959, introduced on October 28 by Senator Ted Kaufman (D-Del.), (along with co-sponsoring Senators Patrick Leahy, Arlen Specter, Herb Kohl, Chuck Schumer, and Amy Klobuchar), especially if you operate a Medicare home care agency in Miami-Dade, Houston, Detroit or Los Angeles.
The Health Care Fraud Enforcement Act of 2009 (S.1959), as drafted, aims to strengthen the U.S. government’s capacity to investigate and prosecute waste, fraud and abuse in government health care programs and private health insurance. (more…)
Analysis by Michael McGowan
Shortcuts are popular and frequently useful. They can also be misleading and dangerous. In the world of payment denials and appeals where I spend most of my time, a popular new shortcut is the audit tool. I am seriously concerned about those who might rely too heavily on such checklists and feel obligated to issue a warning.
Chart audit tools are basically checklists that claim to help you make your charts and visit notes “denial proof.” They cannot possibly live up to that claim. Here is why. (more…)
