All shared games warez dowloadShared games download
free games download with no password, full version games downloadFree Games Download
Download games for free. Bittorrent trackerGames torrents site
Wordpress Themes. Free to download themes for Wordpress blogsFree Wordpress Themes
This is only need to setup your PC.The Setup

A Look at RACs: What Do Physicians, Home Health, Hospice, and DME Providers Need to Know?

June 25, 2010 by  
Filed under Medicare Audits

RAC Auditors are Reviewing Physician Claims(June 25, 2010): The purpose of this series of articles is to assess the Recovery Audit Contractor (RAC) Program from the perspective of physicians, home health, hospice, durable medical equipment (DME) providers, and other relatively small Medicare providers.  As many non-hospital providers will acknowledge, early cries of wolf by law firms and consultants did a fine job of initially publicizing the RAC threat.  Unfortunately, the threat of a RAC audit now appears to be largely ignored by non-hospital providers due to the seemingly widespread sense that RACs will likely continue to focus their efforts on large, institutional Medicare providers – the ultimate “low hanging fruit” in terms of potential Medicare overpayments.

I.     Should Non-Hospital Providers Worry About a RAC Audit?

RACs are, in fact, a real threat to physicians and other small Medicare providers, despite the fact that these particular contractors have passed over these providers in the past.

Over the last six weeks, the Centers for Medicare and Medicaid Services (CMS) has sponsored nationwide conference calls titled “Nationwide RAC 101 Call” specifically aimed at physicians, home health, hospices, and DME providers. Further, CMS conducted two general nationwide conference calls discussing the RAC program that were open to all Medicare providers.

These seemingly innocent informational calls were in fact extraordinarily significant, servicing almost as a “touchstone” for CMS and its RAC auditors.  With the completion of these nationwide teleconferences, outreach has now been completed and CMS can affirmatively state that these non-hospital providers have been given multiple opportunities to learn about the program and prepare for an audit.   All states are now eligible for review.

While CMS must still approve “issues” prior to their widespread review by the RACs, the contractors now have the billing data that they need to analyze and identify possible targets.

II.     What Have Other Provider Experiences with RACs Been?

As physicians and other non-hospital providers prepare for possible audit, it is helpful to review hospitals’ experiences when preparing for and responding to a RAC audit.  On June 22, 2010, the American Hospital Association (AHA) released its findings that the RAC program is having a widespread impact on almost all hospitals, even though many have not even been subjected yet to a RAC audit.[1]  In fact, for the first quarter of 2010 alone:

84% of responding hospitals reported that RACs impacted their organization;

49% of responding hospitals reported increased administrative costs; and

17% of the hospitals using external resources to address RACs hired consultants at an average cost of almost $92,000. 

 So, what do providers and non-hospital Medicare providers need to know about RACs?  This multi-part series will address the following:  First, the purpose and impact of RACs; Second, how to respond to RACs when they come calling; Third, some of the emerging issues for physicians and other small Medicare providers regarding RACs.

III.      What’s a RAC?

The program was created by Section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).  Operating under the direction of the Department of Health and Human Services (HHS), RACs are independent third-party contractors tasked with identifying and correcting improper past Medicare payments.  Each of four RACs has jurisdiction over a separate region of the United States.

After a three year demonstration in which RACs identified $1.03 billion in improper Medicare fee-for-service payments, the program became permanent earlier this year.  CMS created the following table to clarify the role that these contractors are supposed to play compared to others, such as ZPICs.[2]  However, as we will see later in this series, these roles are not clearly delineated and the overlap in the review process can create substantial confusion and waste.

 

Role of Medicare Review Contractors

 

Improper Payment Function

 

 Contractor Performing Function
Preventing future improper payments through pre-pay review and provider education Medicare claims processing contractors
Detecting past improper payments RACs, ZPICs, PSCs
Measuring improper payments CERT [Comprehensive Error Rate Testing]
Performing higher-weighted DRG [diagnosis related group] reviews and expedited coverage reviews QIOs [Quality Improvement Organization]

RACs are incentivized to hunt for evidence of overpayments in high-cost categories of service and to needle out errors that have nothing to do with actual patient care.

IV.     How Are These Types of Contractors Paid?

RACs are paid on a contingency basis so it stands to reason that, during the initial program demonstration, only 4% of improper payments identified were underpayments.  This “bounty hunter” approach also helps to explain why prior audits have focused almost exclusively on high-cost inpatient care services. Recent GAO testimony shed light on this situation and may cause RACs or other contractors to shift their focus to entities that do not have hospitals’ long history of review and compliance, namely physicians and other relatively small Medicare providers.  Finally, a substantial percentage of overpayments collected by RACs during the demonstration program resulted from preventable coding errors, countering the myth that CMS is primarily focused on weeding out unnecessary service claims.

Providers in Region C may want to consider that the AHA found hospitals in that region, encompassing nearly 40% of all U.S. hospitals including those in Texas, Florida, and Virginia, reported the highest number of medical records requested, the highest amount of dollars targeted in medical record requests, and the highest number of denied claims (47% of the $2.47 million in denied claims reported in the first quarter of 2010).

V.     Are There Any Safeguards to Protect Physicians and Other Small Group Providers?

Based on the demonstration program, numerous providers and others have expressed concern that RACs are overly aggressive auditors.  Despite some improvements, concerns about the RAC process are likely to persist.  As recent testimony by the GAO Health Care Director pointed out, the oversight of RACs leaves something to be desired.

Changes have been made to reduce the RACs unintended incentive to drive up fees (through the improper denial of claims). RACs are now required to pay back their contingency fee if the claim is overturned at any level of appeal, rather than just the first level as in the demonstration program.

Additionally, there are some limitations in place regarding the RACs ability to overwhelm providers with record requests.  RACs may not request records more frequently than every 45 days and, for institutional providers, their requests are limited to 1% of all claims submitted for the previous calendar year.  This is an overall limit, however, meaning that a RAC may determine the composition of the records in an additional document request.  They can – and do – request categories of records up to the limit even if the request is disproportionate the provider’s business.

Finally, none of these improvements address the concern that the first several levels of the appeals process do not provide meaningful recourse for the overly aggressive auditing.

robert_w_lile-150x1501Robert W. Liles and Liles Parker attorneys have extensive experience representing health care providers around the country in Medicare appeals cases.  Should you have any questions regarding these issues, don’t hesitate to contact Robert.  For a complementary consultation, you may call us at: 1 (800) 475-1906.


[1] Available at http://www.aha.org/aha/content/2010/pdf/Q1RACTracResults.pdf

[2] Available at http://www.racaudits.com/uploads/RAC_Demonstration_Evaluation_Report.pdf.

Hang on tight — 2010 could be rough . . .

March 1, 2010 by  
Filed under Featured, Guidance

(March 1, 2010):  The number of auditors, reviewers, investigators and prosecutors going after health care providers is increasing and signals an alarming, unprecedented effort by the government to uncover and recover alleged overpayments to health care providers.

 Health care providers now face not only simple repayment demands, but also civil False Claims Act cases and criminal Medicare / Medicaid fraud claims identified by various new government contractors. Regrettably, we have seen unintentional mistakes, incomplete documentation and technical errors cited as the basis for seeking the repayment of millions of dollars, representing Medicare services rendered long ago, in some cases as many seven years before the demand letter was sent.  Perhaps most troubling is the fact that no one, including the ZPIC and / or PSC conducting the medical review, doubts that the medical services were rendered and in most cases, the Medicare beneficiary benefited from the care and treatment provided.  Today, every health care provider must beware of:

  •  “RACs” or Recovery Audit Contractors.
  • “ZPICs” or Zone Program Integrity Contractors.
  • “MICs” Medicaid Integrity Contractors.
  • “MCFU” Medicaid Fraud Control Unit.
  • “HHS-OIG” Department of Health and Human Services, Office of Inspector General.
  • “DOJ” U.S. Department of Justice, and
  • “HEAT” Healthcare Fraud Prevention & Enforcement Task Force (in a number of U.S. Attorney’s Offices around the country).

 RACs and the havoc they are expected to wreak is old news, quite frankly. The newest players in town, ZPICs, MICs and HEAT Teams should be at the top of your current list of concerns.  As you will recall,   CMS consolidated functions of all Program Safeguard Contractors (PSCs) and Medicare Prescription Drug Integrity Control (MEDIC) contracts into ZPIC contracts.  ZPICs are designed to combine claims data (FIs, Regional Home Health Intermediary, Carrier, DMERC) and other data to create a platform for documenting complex data analysis.  While RACs (until recently) have focused solely on recovering money, ZIPCs also look for fraud.

MICs are just now revving up around the country.  Unburdened by many of the restrictions placed on RACs, providers with a heavy Medicaid beneficiary base should diligently review their Medicaid coding and billing efforts to better ensure compliance with applicable statutory and regulatory requirements. 

 HEAT Teams are made up of top level law enforcement and professional staff from DOJ and HHS.  HEAT was implemented to prevent fraud and enforce current anti-fraud laws and prevent waste that focuses on improving data and information sharing between the Center for Medicare & Medicaid Services and law enforcement agencies.  HEAT is working to strengthen program integrity activities to monitor and ensure compliance and enforcement.  HEAT’s tools to identify fraud include hotlines and web sites for healthcare workers and ordinary citizens.  Furthermore, HEAT officials are helping state Medicaid officials conduct better audits and provide better monitoring to detect fraudulent activities.

How should you respond?  The best response is to follow the rules.  If you don’t already have an effective Compliance Plan in place, we recommend you take steps to immediately implement one. 

Liles Parker attorneys represent health care providers around the country in complex Medicare overpayment appeals cases.  Should you have any questions regarding your case, give us a call.  We can you our initial assessment and provide client references.  You may call us for a complimentary consultation at:  1 (800) 475-1906.

National Coverage Determination (NCD) and Local Coverage Determination (LCD) Guidance – How will an ALJ view these coverage guidelines when the Court is assessing whether my Medicare claims should be paid?

February 1, 2010 by  
Filed under ALJ Appeal

(February 1, 2010):  When treating patients, it is not uncommon for a physician to prescribe or utilize certain drugs and / or diagnostic treatments in an “off-label” fashion.  Depending on the insurance policy at issue, this may or may not be covered and paid by a third-party payor.  In the case of Medicare, the Centers for Medicare and Medicaid Services (CMS) has endeavored to better define Medicare’s coverage limits.

National Coverage Determination (NCD) guidelines describe the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare coverage is limited to:

  • Items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).
  • Determinations developed through an evidence-based process, with opportunities for public participation. In some cases, CMS’ own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).

Importantly, once an NCD is finalized and published, its coverage guidelines are binding on all Medicare contractors (including Program SafeGuard Contractors, Zone Program Integrity Contractors, Recovery Audit Contractors, Medicare Administrative Contractors (formerly Fiscal Intermediaries and Carriers) and Qualified Independent Contractors). Notably, NCDs are also binding on ALJs and the Medicare Appeals Council.

As set out in the Code of Federal Regulations:
42 C.F.R. § 405.1060   Applicability of National Coverage Determinations (NCDs).

(a) General rule. (1) An NCD is a determination by the Secretary of whether a particular item or service is covered nationally under Medicare.

(2) An NCD does not include a determination of what code, if any, is assigned to a particular item or service covered under Medicare or a determination of the amount of payment made for a particular item or service.

(3) NCDs are made under section 1862(a)(1) of the Act as well as under other applicable provisions of the Act.

(4) An NCD is binding on fiscal intermediaries, carriers, QIOs, QICs, ALJs, and the MAC.

(b) Review by an ALJ. (1) An ALJ may not disregard, set aside, or otherwise review an NCD.

(2) An ALJ may review the facts of a particular case to determine whether an NCD applies to a specific claim for benefits and, if so, whether the NCD was applied correctly to the claim.

(c) Review by the MAC. (1) The MAC may not disregard, set aside, or otherwise review an NCD for purposes of a section 1869 claim appeal, except that the DAB may review NCDs as provided under part 426 of this title.

(2) The MAC may review the facts of a particular case to determine whether an NCD applies to a specific claim for benefits and, if so, whether the NCD was applied correctly to the claim.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a Local Coverage Determination (LCD).

An LCD (as established by Section 522 of the Benefits Improvement and Protection Act), is a coverage decision by a Medicare Administrative Contractor (previously issued by a Fiscal Intermediary (Part A) or Carrier (Part B) contractors).  LCDs are drafted to cover  a particular service as reasonable and necessary on a contractor-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act.

Unlike an NCD, ALJs are not bound to follow an LCD.  Nevertheless, ALJs will give LCD coverage guidelines considerable weight. In representing health care providers, we work hard to persuade an ALJ that the services at issue do, in fact, qualify for coverage.

As set out in the Code of Federal Regulations:

42 C.F.R. § 405.1062   Applicability of Local Coverage Determinations (LCDs) and other policies not binding on the ALJ and MAC.

(a) ALJs and the MAC are not bound by LCDs, LMRPs, or CMS program guidance, such as program memoranda and manual instructions, but will give substantial deference to these policies if they are applicable to a particular case.

(b) If an ALJ or MAC declines to follow a policy in a particular case, the ALJ or MAC decision must explain the reasons why the policy was not followed. An ALJ or MAC decision to disregard such policy applies only to the specific claim being considered and does not have precedential effect.

(c) An ALJ or MAC may not set aside or review the validity of an LMRP or LCD for purposes of a claim appeal. An ALJ or the DAB may review or set aside an LCD (or any part of an LMRP that constitutes an LCD) in accordance with part 426 of this title.

Liles Parker attorneys have extensive experience representing health care providers in ALJ hearings.  Call us to discuss your case.  Your initial consultation is complementary.  We can be reached at:  1 (800) 475-1906.

Finally, Time to Have Our Case Heard by an Administrative Law Judge. What Should I Expect?

February 1, 2010 by  
Filed under ALJ Appeal

(February 1, 2010):  Over the years, our attorneys have argued cases before Administrative Law Judges (ALJs) working out of each of the Office of Medicare Hearings and Appeals field offices around the country.  Based on our collective experience, we believe that this level of appeal is a health care provider’s best opportunity to present its arguments in support of payment in an administrative overpayment cases.  While each ALJ operates his / her hearing in a slightly different fashion, we have found each of  the Judges we have practiced before to be highly experienced, fair and more than willing to hear our Client’s side of the story.  That’s the good news.

The bad news is that it can take years before a case is finally heard.  That’s not the fault of the Judge – it’s just the way the system is structured. In order to meet the jurisdictional requirements, at least $130 (this is a new jurisdictional amount starting  in 2010) must remains in controversy following the Qualified Independent Contractor’s (QIC’s) decision.  A health care provider (or their representative) must request an ALJ hearing within 60 days of receipt of the QIC’s reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration.  Always keep in mind that the Court will be conducting a “de novo” review.  Moreover, the Court isn’t bound by lower decisions, even if they were in your favor.

It is essential that requests for ALJ hearing be filed in a timely fashion.  It is extraordinarily difficult to show “good cause” for a late filing.  While the ALJ will assume that the QIC decision was received 5 days after the date of the date decision (effectively giving an appellant 65 days from the date of the QIC decision letter), it is prudent to ignore the 5 day mailing allowance and ensure that a request for ALJ hearing is received within 60 days of the QIC decision letter.  Moreover, requests for ALJ hearing should only be sent by mail that can be tracked so that timely receipt can be verified.  Don’t forget, FedEx and UPS do not typically deliver to a P.O. Box address.  Be prepared to use U.S. Postal Service’s overnight express.

ALJ hearings are generally held by video-teleconference or by telephone. Depending on the size of the case and other factors (such as the ability of your Client to fully explain medical or scientific evidence by teleconference), you may desire to request an in-person hearing.  In order to justify the need for an in-person hearing, you will be required to show “good cause.”  The decision of whether or not to grant an in-person hearing rests with the ALJ.  Whenever possible, we typically present our Client’s arguments in support of payment by teleconference.  We have found this approach to be both cost-effective and convenient for our clients and the Court.

In some cases (where no live testimony is needed, the record is well documented and the amount in controversy is low – typically less than $1,000), we have asked the Court to conduct its review on the record, without conducting a hearing.

In the last few years, we have seen a dramatic increase in the number of hearings attended by representatives of the Program SafeGuard Contractor and / or the QIC.  More often than not, they identify themselves as “participants” rather than as a “party.”  This typically occurs in cases involving the statistical extrapolation of alleged damages.

The Court will usually issue its decision within 90 days, although this time period is often waived in order to give the Court ample time to consider the issues presented.

Should you disagree with the ALJ’s decision, you may appeal it to the Medicare Appeals Counsel.

Should you have any questions regarding these issues, don’t hesitate to contact us.  Liles Parker attorneys have represented a wide variety of health care providers around the country in ALJ appeals and hearings.  We have the knowledge, skills and abilities to persuasively present your case.  For a complementary consultation, you may call us  at: 1 (800) 475-1906.

Final Rule Outlining Recoupment Limitations and the Impact on Ongoing Medicare Overpayment Appeals Cases

February 1, 2010 by  
Filed under Featured, Medicare Audits, Recoupment

(February 1, 2010):  Last September, the Centers for Medicare and Medicaid Services (CMS) published its Final Rule addressing limitations on the recoupment of alleged overpayments by its Medicare contractors (e.g. Medicare Administrative Contractors and Qualified Independent Contractors).  This Final Rule finalizes how Medicare contractors are to proceed when pursuing recoupment actions of alleged overpayments owed by a health care provider.   “Recoupment” is defined as the recovery of a Medicare overpayment by reducing present or future Medicare payments and applying the amount withheld against the debt.

Under existing regulations, health care providers may postpone recoupment by engaging in the administrative appeals process.  Prior to passage of the Medicare Modernization Act (MMA), CMS could recoup overpayments, regardless of whether the provider or supplier had filed an appeal challenging an alleged overpayment.  With CMS’ Final Rule in place, limitations have been set on the ability of its Medicare contractors to pursue a recoupment action.  As the Federal Register states:

“This final rule defines the overpayments to which the limitation on recoupment applies, how the limitation works in concert with the appeals process, and sets time limits for recouping overpayments, specifically providing 41 days for a provider or supplier to file the first level of appeal before the contractor can begin recoupment and providing the provider or supplier 60 days to appeal at the second level before the contractor can begin recoupment” (74 Fed. Reg. 47458, 47458 (Sept. 16, 2009)).

Notably, a Medicare contractor may freely initiate recoupment on an overpayment once a reconsideration decision has been rendered, regardless if an Administrative Law Judge (ALJ) appeal has been filed or is going to be filed.

Should a provider elect to delay recoupment, the amount owed will be subject to the Medicare interest rate. This amount varies but is generally quite high. For example, as of January 25, 2010, the interest rate has been set at 11.25 percent.  As such, it is especially important that providers consider the following:

(1) If an overpayment determination is overturned past the reconsideration level of appeals, CMS is liable for interest on recouped overpayments that has accrued.

(2) If a health care provider or supplier takes advantage of the limitation on recoupment and ultimately loses an administrative appeal, the provider is liable for all interest accrued since the original determination, along with the overpayment which remains after going through the administrative appeals process.

While the Medicare interest rate is quite high, it is essential that health providers understand the nuances of the administrative appeals process before rushing to postpone recoupment.  For example, to avoid recoupment after a redetermination appeal decision has been issued, a provider (or its representative) must file for  reconsideration appeal within 60 days.  Should they choose to do so, they will be forfeiting the statutory right to avail themselves of the full 180 period that is permitted to file for reconsideration appeal – merely to avoid the initiation of recoupment.  In some cases, a provider would be better off taking the necessary time (up to 180 days) to ensure that its files are complete and its arguments in support of payment are fully developed prior to filing their appeal.  Filing an incomplete appeal within the 60 day deadline may ultimately harm, rather than help a provider’s chances of prevailing on appeal.

Ultimately, CMS’ Final Rule makes it more important than ever that health care providers undergoing overpayment review get qualified, experienced legal advice to help guide them through the administrative appeals process.

Should you have any questions regarding these issues, don’t hesitate to contact us.  For a complementary consultation, you may call Robert W. Liles or one of our other attorneys at 1 (800) 475-1906.

« Previous Page

Main Menu
Main Menu