Breaking News May 2011
Critical Access Hospitals
- RAC auditors denied claims on several Critical Access Hospitals for untimed therapy codes CPT 92507. Treatments for speech, voice, communications etc. services billed for 8 different days/4 units a day. RAC auditors are only allowing 1 service per day. Recoupment was taken for all other services billed.
- RAC denials on critical access hospital claims are reflected on their final PS&R and audited cost report and will affect future year interim rate payments.
Acute Care Hosptials & Physician
- Providers are reporting problems on the RAC audits, such as not getting their demand letters on time. Recently providers have reported $ deducted from their remittance advices with no explanation or error codes. It is Important for providers to reconcile all remittance advices. Hospitals wind up chasing down money that Medicare recouped inappropriately from RAC automated or semi automatic reviews which becomes a nightmare for the facility. Read about semi-automated reviews on the CMS website at: http://questions.cms.hhs.gov/app/answers/detail/
- RAC semi-automated reviews sound like automated reviews because they are based on CMS claims analysis and appear to steer clear of MS-DRG coding validation and medical necessity. Semi-automated reviews have more in common with complex reviews because hospitals must submit medical records unless they're willing to sacrifice their reimbursement without a fight. The great unknown is whether there's a cap on the number of semi-automated reviews that RACs can perform at each hospital. RACs can do unlimited automated reviews because hospitals aren't required to submit medical records as a part of the process. However, CMS caps the number of complex reviews RACs may conduct every 45 days, otherwise providers would be overwhelmed by the requests. Recently CMS upped the limit to 500 claims per hospital every 45 days. CMS has not indicated whether there's a ceiling for semi-automated reviews.
Articles & Links
Articles published in Washington Healthcare News
- July, 2010: 15.6 Billion Returned to the Medicare Trust Fund From All Fraud Audit Recoveries Since Inception in 1997
- September, 2008: Recovery Audit Contractors Are Not Going Away...Will Your Facility Survive the Assault?
- December, 2008: OIG Holds Hospital Boards Accountable on Fraud Audits
- March, 2009: Boost Your Critical Access Hospital Bottom Line Swing Bed Designation
- September, 2009: How Benchmarking Can Help Your Facility Achieve Financial Wellness
- March, 2010: Government Budget Deficits Triggering Increased Provider Audits
FCAW's Most Recent Newsletter
- January 2011 Articles Include:
- RAC results 6-30-2010
- CMS approves new RAC issue for Region D
- Patient Protection Act expands fraud audit
- Department of Justice recovers $3 billion false claims
- OIG FY 2011 high risk focus
- Expansion 2011 Medicaid RAC
- Zone Program Integrity Audit update
- New provisions CAH
- CMS is extending through 2011 filing deadline
- New codes for 2010-2011 seasonal flu vaccines
- New Medicaid deductible & coinsurance
- LTCH PPS market basket
- Changes to OPPS
- ASC payment rate update
- G codes wellness visit
- IHS facilities may be required to file full cost report
- Previous FCAW newsletters available upon request
Request our complimentary newsletter
Other Resources
- Long Term Care Corporate Integrity Agreements
- OIG Semiannual Report to Congress
- Critical Access Hospital Regulation Update
- MedPAC releases comments to CMS on reform
- MedPAC June 2009 Report to Congress
Federal Government Links
- HHS Medicare
- U.S. Government official web portal
- HHS Office of Inspector General
- HHS Skilled Nursing Facility Center
- 2010 MLN Matters Articles
- HHS CERT overview
- Code of Federal Regulations (CFR)
State of Alaska Medicaid
- Alaska Health Care Services
- Alaska Medicaid State Plan
- Alaska Medicaid- Alaska Medical Assistance
- Medicaid Rate Advisory Commission
- Alaska Statutes
State of Washington
- Department of Social & Health Services
- State of Washington Aging & Disability Services Administration
State of Oregon
State of Idaho
State of Montana
Private Resources
