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…)
It is becoming apparent that certain cities have been targeted by recently stepped-up CMS efforts to protect the Medicare trust fund from inadvertent or fraudulent overpayments. Wise administrators and owners in non-targeted regions are watching what is going on in Miami, Houston and Los Angeles carefully, learning from the experiences of their colleagues there. Here is one unidentified agency’s story. (more…)
As we have previously reported, RAC auditors are prohibited from investigating overpayments arising from any clinical or administrative issues that were not on the table during the 3-year RAC demonstration project. One by one, the collection agencies that hold RAC contracts have been adding to the list of issues, applying for and getting CMS approval for issues not addressed during the demonstration. Below is a complete list of issues approved by CMS since the demonstration project ended and permanent contracts were awarded. As you will see from this week’s list, RACs are not looking at home care yet. (more…)
Home care and hospice can breathe easy for a while, but only about this one issue.
Recovery Audit Contractors (RAC) are limited in the issues they can use to recoup funds from Medicare providers. It is important that all providers learn what those issues are and keep themselves updated as they change.
Initially, RACs may only look for overpayments and underpayments resulting from issues that arose during the 3-year demonstration project. Since home care and hospice were not addressed during the demonstration, those two healthcare segments are (more…)
It has just become far more likely that Medicare will take disputed money while healthcare providers pursue payment denial appeals instead of waiting to collect it until a decision has been reached at the end of the process. On September 16, 2009, CMS published a Final Rule implementing Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) that dramatically changes its previous working interpretation of the rule. (more…)
by Julianne Haydel, RN
Agencies often ask their consultant, “What do we have to do in order to pass survey?” Frankly, a complete answer would be so lengthy it is easier to ask how to flunk one. I can answer that one authoritatively because I have firsthand knowledge on how to completely bomb a survey. Follow the instructions below and it is almost guaranteed that you will find yourself in survey hell shortly after the state comes knocking on your door. (more…)
Recovery Audit Contractors (RAC) are expected to turn their attention to home health care providers sometime next year, looking for reasons to recoup PPS episode payments received as far back as October, 2007. If, as is anticipated once they get started, they use the same reasons Regional Home Health Intermediaries (RHHI), Qualified Independent Contractors (QIC) and Administrative Law Judges (ALJ) are currently using to deny payments, agency management can secure a tactical advantage by studying those reasons now.
There are two ways to prepare for the RACs. One is prevention, the other cure:
- help your clinicians improve their documentation skills
- learn how to navigate the appeal process
This week, we focus on the cure, all the while continuing to hope your prevention efforts, which this newsletter will frequently address, will make the cure mostly unnecessary.
Case study: Much ado about nothing one visit
The following example, drawn from an actual payment denial case (more…)
It will still be several months before home care providers begin to experience Recovery Audit Contractor activity. As we have explained in previous articles, each contractor must first file an application with CMS for permission to examine home care agencies. Following that, that must provide training in the region they intend to enter.
The permission requirement stems from the law creating the RACs. It limited their activities to exactly what was done during the 3-year demonstration project. Since no home care agencies were approached by the demonstration contractors, the permanent contractors cannot work in home care, or hospice, without CMS approval. Regarding the training requirement, we have heard of only two instances so far where a contractor attempted to provide it, one in New Jersey and one in Ohio. In both instances, the trainers seemed to know little or nothing about home health care.
While waiting, we continue to help readers brush up on the basics of the appeals process following existing payment denial methods. Though RACs will take your money in new ways and for new reasons, the process of recovering it will be the same. The following is from a guide CMS published recently, informing Medicare beneficiaries and providers about their rights and responsibilities under today’s appeals rules. (more…)
We confront home care and hospice’s toughest problems through five topical newsletters.
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This is the fourth and last in our series based on our July interview with NAHC attorney Denise Bonn and her presentation to the NAHC Financial Managers meeting.
Read the rest of the series:
- Part One: RAC Startup Plans,
- Part Two: OIG Questions Paltry 1.4% Denial Rate,
- Part Three: Four Distinct Entities Want to Deny Your Payments
Protecting your agency from suffering potentially crippling claims denials and payment recoupments while CMS fights fraud and abuse with multiple layers of redundant auditors will require significant planning and advance defensive measures. Agencies that take the attitude, “We’re not intentionally breaking the law, we don’t have anything to fear from these new auditors,” are at high risk.
