Recovery Audit Contractors (RACs) Archives | / Blog

RAC Posts First Home Health Issue

2012-02-14T16:18:49Z

Connolly Healthcare, RAC for Region C, has recently added its first home health agency issue to its CMS-approved issues list. The first posted issue targeting home health agencies is an automatic review that will focus on partial episode payments (PEPs). The Medicare Claims Processing Manual defines a PEP as "a reduced episode payment that may be made based on the number of service days in an episode (always less than 60 days, employed in cases of transfers or discharges with readmissions)." The approved home health issue is described below.

Incorrect billing of home health partial episode payment claims. Incorrect billing of home health PEP claims identified with a discharge status 06 and another home health claim was not billed within 60 days of the claim from date. Additionally, MCO effective dates are not within 60 days of the PEP claim.

Home health agencies should be on high alert for RAC audits. In addition, providers may expect additional home health issues to be added for review in the future, including complex reviews. If you are a home health agency, or any other provider type, and need assistance defending against RAC audits or implementing a compliance program that will help identify and correct potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.

Recent RAC Activity

2012-02-14T16:13:22Z

Connolly Healthcare recently added 17 new issues to its CMS-approved issues list for Region C states. Below is a sampling of the recently approved issues, which fall in multiple categories. For a full list and more information please visit the Connolly website.

Ambulance/transport during a SNF stay to or from a diagnostic or therapeutic site: Ambulance/transport services provided during a SNF stay are not separately paid under the Part B benefit. The cost for these services is considered part of the Part A Prospective Payment made to the SNF Provider. Ambulance transports to or from a diagnostic or therapeutic site other than a hospital or renal dialysis facility (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center, etc.). The ambulance transport is included in the SNF PPS rate if the first or second character (origin or destination) of any HCPCS code ambulance modifier is "D" (diagnostic or therapeutic site other than "P" or "H"), and the other modifier (origin or destination) is "N" (SNF). The first SNF is responsible for billing the services to the FI.

Inappropriate Payments for Transformational Epidural Injections: Local Coverage Determination policy has indicated specific conditions or diagnoses that are covered for Transformational Epidural Injections. Carrier claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies.

Incorrect diagnosis code billed for blood clotting factor: An overpayment exists when a provider bills for a blood clotting factor with an ICD-9 code that is not included in the list of covered ICD-9 codes within the applicable Local Coverage Determination document(s).

Improper payments for Facet Joint Injections: An overpayment exists when a provider bills for an Facet Joint Injection with an ICD-9 code that is not included in the list of covered ICD-9 codes within the applicable Local Coverage Determination document(s).

Incorrect billing of Home Health Partial Episode Payment claims: Incorrect billing of Home Health Partial Episode Payment (PEP) claims identified with a discharge status 06 and another home health claim was not billed within 60 days of the claim from date. Additionally, MCO effective dates are not within 60 days of the PEP claim.

HealthDataInsights recently added new issues to its CMS-approved issues list for Region D states. Below is a sampling of the recently approved issues. For a full list and more information please visit the HealthDataInsights website.

Acute Inpatient Hospitalization - Bowel and Rectal Procedures (DRG 329, 330, 332, 333, 334, 344, 345 and 346): Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Acute Inpatient Hospitalization - Hepatobiliary Procedures (DRG 420, 421, 422, 424 and 425): Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

If you need assistance defending against RAC audits or implementing a compliance program that will help identify and correct potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.

CMS Announces New Start Date for Prior Authorization of PMDs and Recovery Audit Prepayment Review Demonstration Programs

2012-02-06T18:35:16Z

The Centers for Medicare and Medicaid Services (CMS) has announced that the Prior Authorization of Power Mobility Devices (PMDs) and the Recovery Audit Prepayment Review Demonstration Programs are expected to move forward on or after June 1, 2012. On December 30, 2011, the two demonstrations were delayed from their initial January 1, 2012 start date. Although CMS initially announced the demonstration programs in November 2011, CMS decided to delay the programs' implementations after receiving considerable feedback from the provider communities affected by the programs.

In its most recent announcement, CMS stated that the demonstrations programs will begin once they receive Paperwork Reduction Act (PRA) Office of Management and Budget control numbers.

The Prior Authorization of PMDs demonstration program will be initiated in California, Illinois, Michigan, New York, North Carolina, Florida, and Texas. These are all states with high populations of fraud- and error- prone providers. The demonstration will implement a prior authorization process for scooters and power wheelchairs.

As a result of comments CMS received from providers and suppliers, significant modifications have been made to the Prior Authorization of PMDs demonstration program. Most importantly for suppliers, the 100% pre-payment review phase has been removed. Many interested parties had raised the concern that suppliers would be adversely financially impacted by the 100% pre-payment review phase, thus CMS eliminated it and the demonstration will begin immediately with the prior authorization phase. There was also concern regarding the inconsistency of suppliers in some states experiencing 100% pre-payment review, while suppliers in other states were required to receive prior authorizations. The pre-payment review phase was planned to last from between three to nine months for each state, so while one state might only be in that phase for three months, another state might be for nine. As a result, all demonstration states will start prior authorization at approximately the same time instead of the staggered start times as originally planned.

CMS also received many concerns about the ordering physician possibly not being in the best position to submit the prior authorization request. Under the modified demonstration, the physician/treating practitioner or supplier, on behalf of the physician/treating practitioner, may perform the administrative function of submitting the prior authorization request.

The Pre-Payment Review Demonstration Program did not receive any significant changes and will be implemented as proposed in November.

For more information on prior authorization, pre-payment review, or other CMS demonstrations, please contact a Wachler & Associates attorney at 248-544-0888.

CMS' Q4 Audit Program Activity: $353.7 Million in Improper Payments, Increased Focus on Medical Necessity Claims

2012-01-30T18:31:33Z

The Centers for Medicare and Medicaid Services (CMS) publishes quarterly reports identifying improper payment figures and the top audit issues by region. The most recent "Q4" report, covering July 1, 2011 to September 30, 2011, demonstrates a 22% increase in the total correction amount from the previous quarter.

During this period, CMS identified $277.1 million in overpayments and $76.6 million in underpayments, for a total correction amount of $353.7 million. This figure represents a dramatic increase from the two previous quarterly improper payment totals of $208.9 million (Q2) and $289.3 million (Q3). The boost, which is consistent across all regions, indicates that individual recovery auditors nationwide are increasing their efforts to identify incorrect payments, and further supports the industry-wide belief that audits are expanding.

The Q4 recovery audit program update also demonstrates that auditors are increasingly targeting "medical necessity" claims, with a focus on supporting documentation and the setting in which these services are provided. The Q4 update highlighted the following "top issues per region" of the recovery audit program:

Region A - Renal and Urinary Tract Disorders: (Medical Necessity) Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation for patients with renal and urinary tract disorders needs to be complete and support all services provided.

Region B - Surgical Cardiovascular Procedures: (Medical Necessity) Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation for patients with surgical cardiovascular procedures needs to be complete and support all services provided.

Region C - Acute Inpatient Admission Neurological Disorders: (Medical Necessity) Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation for patients admitted with neurological disorders needs to be complete and support all services provided.

Region D - Minor Surgery and other treatment billed as Inpatient: (Medical Necessity) When beneficiaries with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for less than 24 hours, they are considered outpatient for coverage purposes regardless of the hour they presented to the hospital, whether a bed was used, and whether they remained in the hospital after midnight.

Wachler & Associates has served healthcare providers and suppliers nationwide for over 25 years. We currently represent healthcare entities in all stages of the audit appeals process, and specialize in defending the medical necessity of inpatient admissions.

CMS Clarifies Procedure for MAC Claims Against DMEPOS Suppliers' Surety Bonds

2012-01-27T19:19:24Z

All Medicare suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) must obtain and maintain a surety bond of at least $50,000 to participate in the Medicare program. A Centers for Medicare and Medicaid Services (CMS) recent transmittal, effective February 21, clarifies this requirement and describes the procedures that DME Medicare Administrative Contractors (MACs) must follow when making claims against a provider's surety bond.

Under 42 CFR § 424.57(d)(5)(i), a surety is liable to CMS for 1) the amount of any unpaid claim, plus accrued interest, for which the supplier of DMEPOS is responsible, and 2) the amount of any unpaid claim, civil monetary penalty (CMP) or assessment imposed by CMS or the Office of Inspector General (OIG) on the DMEPOS supplier, plus interest.

First, the DME MACs will notify the surety that payment of a claim must be made to CMS within 30 days. The letter must 1) identify the specific amount to be paid, 2) be accompanied by "sufficient evidence" of the unpaid claim, 3) state that payment shall be made via check or money order and that the Payee shall be the DME MAC, and 4) identify the address to which payment shall be sent. The DME MAC will notify the supplier when payment has been made.

DMEPOS suppliers must then obtain an additional surety bond within 30 calendar days of that letter, and submit to the National Supplier Clearinghouse (NSC) additional coverage of an amount that equals or, in the case of a final adverse action, exceeds $50,000. Suppliers must be aware that failure to submit such additional surety bond coverage within 30 days may result in the NSC revoking the supplier's Medicare billing privileges.

If the DMEPOS supplier successfully appeals, CMS will notify the surety via letter and repay the surety within 30 days. Although a supplier may want to avoid the necessity of securing an additional surety bond, the DMEPOS appeals process may take longer than 30 days and prudent DMEPOS suppliers should obtain additional coverage to ensure continued Medicare billing privileges.

Wachler & Associates has served healthcare providers nationwide for over 25 years in a variety of issues, including DME Audits and all areas of Medicare Compliance.

RACs Target Skilled Nursing Facilities with High Therapy Resource Utilization Groups

2012-01-23T18:16:51Z

Recent Recovery Audit Contractor (RAC) activity demonstrates that the Centers for Medicare and Medicaid Services (CMS) may soon allow RACs to target skilled nursing facilities (SNFs) with certain levels of Ultra High Therapy Resource Utilization Groups (RUGs).

Although Ultra High Therapy Resource Utilization Groups are not currently a CMS-approved audit topic, RACs are permitted to audit "test claims" and suggest new audit activity based on the results. In a recent demand letter, the RAC stated that the Office of Inspector General (OIG) of the U.S. Department of Health & Human Services has found an "overwhelming majority of error in assignments by providers under the RUGs categorization system to Ultra High Therapy RUGs, resulting in overpayments to SNFs."

These claims arose out of a 2010 OIG report which alleged that 1) SNFs are increasingly billing higher-paying RUGs, 2) for-profit SNFs are more likely than nonprofit SNFs to bill for higher-paying RUGs, and 3) in general, many SNFs maintain questionable billing for therapy services.

Specifically, the RAC claims that the OIG identified as "...errors in the sample could be traced to the providers' therapy minutes recorded on the Minimum Data Set not matching the minutes recorded in the medical record and the patient's care and resource needs." Further, it seems that SNFs with 10-15% of residents in the Ultra High Therapy RUGs category may be subject to RAC audits.

If the issue is approved by CMS, RACs will begin burdensome document requests and therapy audits nationwide. Providers of Ultra High Therapy RUGs should consider self-auditing internal records in order to ensure that the minutes of therapy and other medical records support the therapy provided.

If you need assistance with an internal audit, or implementing compliance program to identify and correct potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.

Recent RAC Activity

2012-01-17T14:27:50Z

DCS Healthcare, RAC for Region A, recently added 40 new issues to its CMS-approved issues list for providers in Pennsylvania, Delaware, Connecticut, New Jersey, New York, New Hampshire, Massachusetts, Maine, Vermont and D.C. A sampling of the newly approved issues is included below. Please visit DCS Healthcare's website to view the remaining issues.

Medical Necessity Review (MNR) for MS-DRG 922 Other Injury, Poisoning and Toxic Effect Diagnosis with MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 922 Other Injury, Poisoning and Toxic Effect Diagnosis with MCC.
Medical Necessity Review (MNR) for MS-DRG 464 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 464 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC.
Medical Necessity Review (MNR) for MS-DRG 617 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC Disorders with CC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 617 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC.
Medical Necessity Review (MNR) for MS-DRG 215 Other Heart Assist System Implant. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 215 Other Heart Assist System Implant.
Medical Necessity Review (MNR) for MS-DRG 734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC-MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC-MCC.
Medical Necessity Review (MNR) for MS-DRG 836 Acute Leukemia without Major O.R. Procedure with CC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 836 Acute Leukemia without Major O.R. Procedure with CC.
Medical Necessity Review (MNR) for MS-DRG 340 Appendectomy with Complicated Principal Diagnosis without CC-MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 340 Appendectomy with Complicated Principal Diagnosis without CC-MCC.

Connolly Healthcare, the RAC for Region C, recently added two new issues to its CMS-approved issues list.

Incorrect payments for Maintenance and Servicing of capped rental DME. Payment for maintenance and servicing of capped rental DME equipment is included in the rental payments, and should not be reimbursed separately.
Incorrect modifiers billed with bilateral indicator 2 - OP. Certain modifiers cannot be billed with Bilateral Surgery Indicator 2 because the Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure.

CMS has Delayed the Recovery Auditor Pre-Payment Review Demonstration Program

2012-01-03T15:59:20Z

Last week, CMS announced its decision to delay the Recovery Auditor Pre-Payment Review Demonstration Program until further notice. On its website CMS indicated that the delay was due to comments/suggestions received regarding the program and CMS' commitment to consider the comments carefully. Although it is unclear at this time whether CMS will eventually implement the demonstration program as it was initially announced or make significant changes to the program, CMS confirmed that it will provide at least 30 days notice before the demonstration program begins.

For more information on pre-payment review and strategies to utilize if on pre-payment review, please contact Wachler & Associates attorney at 248-544-0888 or visit www.racattorneys.com.

CMS AB Demonstration Program: Hospitals' Participation in December 8 Open Door Forum

2011-12-05T18:59:34Z

As discussed in earlier posts, hospitals that participate in CMS' upcoming Part A to Part B Rebilling Demonstration Program will be required to waive their right to appeal claims denied for lack of medical necessity for services provided in the inpatient setting. CMS' rationale for this "all or nothing" approach is the concern that a participating hospital could appeal the denial of the Part A inpatient claim and at the same time resubmit the claim for Part B reimbursement. As any participating provider that intentionally engages in that type of billing practice would expose themselves to liability for double-billing, it is unrealistic for CMS to anticipate that participation in the demonstration program would encourage this behavior. During the RAC demonstration programs, in which hospitals were afforded the flexibility denied to them for the AB demonstration program, there was no evidence that hospitals tried to "game" the system.

Further, despite CMS' overreaching concerns that hospitals will take advantage of a more flexible demonstration program that allowed case-by-case appeals, the agency's concerns do not extend to the likelihood that RACs will take advantage of the demonstration program's structure. CMS claims that the RACs will not know the hospitals that participate in the demonstration program, and therefore will not have an incentive to deny more claims from those hospitals knowing that they are immune from appeals. However, RACs will very likely know the participants because those hospitals will not submit appeals for the denied inpatient claims and the RACs will receive smaller contingency fees for those denied claims.

We strongly urge hospitals to participate in the CMS' December 8 special Open Door Forum (details below). During the Open Door Forum, hospitals should express their dismay with the current structure of the demonstration program, specifically the waiver of any appeal rights for denied inpatient claims. In addition, hospitals must incorporate into their RAC appeals process the effort to obtain Part B payment for inpatient services denied as not medically necessary. Only through a concerted effort by the hospital industry will we convince CMS to modify the current rebilling system.

For assistance with the appeals process, please visit www.racattorneys.com or contact a Wachler & Associates attorney at 248-544-0888.

CMS Special Open Door Forum for the Part A to Part B Rebilling Demonstration Program: December 8, 2011 at 2pm-3:30pm ET. Dial: 1-866-501-5502 Reference Conference ID#: 28779067 (Please dial in at least 15 minutes prior to call start time)

Open Door Forum for Part A to Part B Rebilling Demonstration Program

2011-11-30T23:11:36Z

This afternoon, CMS conducted the first special Open Door Forum (ODF) on the Part A to Part B Rebilling Demonstration Program. The ODF involved a brief overview of the Demonstration Program followed by many questions by the ODF participants. Although the ODF provided some clarification on the Demonstration Program, CMS' answers also gave rise to many concerns regarding the fairness of the Demonstration Program.

One of the most serious concerns is a Demonstration Program participant's right to appeal a denial of an inpatient claim. According to CMS' answers from callers' questions, participation in the Demonstration Program is "all-or-nothing". This means that if a participant's claim is denied for lack of medical necessity for services provided in the inpatient setting, the participant's only option is to resubmit the claim for outpatient reimbursement. Even if the participant disagrees with the contractor's denial of the inpatient claim, the participant will not be allowed to appeal the inpatient denial. Clearly this limitation has very serious consequences for hospitals because it requires participants to waive all of their due process rights for these claims. First, between the RAC Demonstration Program and Permanent Program we have had success in overturning 90% of short-stay inpatient claims denied for services provided in the wrong setting. Accordingly, requiring a hospital to waive the right to challenge these denials appears to be a high price to pay to participate in the AB Demonstration Program. The limitation highlights the inequity of a system where a provider must choose between either appealing the denial of an inpatient claim, but being unable to rebill the claim for outpatient reimbursement or rebilling the claim for 90% reimbursement of the outpatient claim, but waiving all due process rights.

In a program where RACs are paid through a contingency fee based upon the dollar amount of claims they deny, it is concerning that RACs now have an incentive and unbridled discretion to deny inpatient claims where there will be no right to appeal. During the ODF, CMS insisted that the RACs will not be informed of the hospitals participating in the demonstration program and thus, will not have an incentive to deny more inpatient claims. However, RACs will likely be able to deduce the participants because the participants will not appeal any inpatient claim denials and RACs contingency fee for participants will be different from non-participants. Specifically the contingency fees that RACs will receive as a result of denials from participants will not be the contingency fee of the full inpatient claim or the outpatient claim, but of the difference between the full inpatient claim and outpatient claim. This differential will be unique to program participants. Therefore, it is likely that RACs will know the participants of the Demonstration Program and could target them because of the participants' inability to appeal denied inpatient claims.

In the initial RAC Demonstration Program for six states, hospitals were allowed to rebill at any time during the appeals process. At a minimum, we urge hospitals to request that CMS allow an AB Demonstration Program participant to make a determination on a claim-by-claim basis on whether to rebill a claim for outpatient services or to appeal the denied inpatient claim.

For more information on the Demonstration Program, or to discuss the audit appeals process with a Wachler & Associates attorney, please visit www.racattorneys.com or call 248-544-0888.

CMS Releases Last Quarter's Data on Medicare RAC Collections

2011-11-30T19:03:08Z

The Centers for Medicare and Medicaid Services (CMS) has recently released the Medicare RAC collections data for the last quarter of 2011 fiscal year. Recovery auditors identified $277.1 million in overpayments and $76.6 million in underpayments, for a total claims' correction of $353.7 million, which was 22 percent higher than the total corrected claims identified in the previous quarter.

CMS also released a supplemental report for the entire 2011 fiscal year. The total identified claim corrections for the fiscal year was $939.4 million in collected overpayments and $141.9 million in returned underpayments. These amounts greatly outnumber the corrected claims identified from 2010 fiscal year.

Currently, CMS' quarterly reports fail to mention the success rates of appeals, which would decrease the identified claim correction amounts. However, CMS has stated that it will begin to make official appeal rates available in its annual Report to Congress.

CMS Releases Part A to B Rebilling Demonstration Program Enrollment Application

2011-11-29T21:22:54Z

This week CMS released more information regarding the Part A to Part B Rebilling Demonstration Program. Now available on CMS' website is the enrollment application for hospitals to complete to seek to participate in the program. The enrollment application includes language which reiterates that participation in the Demonstration Program is based on a first-come first-served process and applications will be classified based on facility size. According to the application, 80 large facilities (300+ Beds), 120 moderate facilities (100-299 Beds), and 180 small facilities (fewer than 100 Beds) will be allowed to participate.

In addition to the enrollment application, CMS published a 14-page document which outlines some of the Demonstration Program's details. The document, which may have been released in anticipation of the upcoming Open Door Forums, includes four requirements that participating providers must follow: (1) Not file an appeal; (2) Not bill the beneficiary more than any Part A inpatient deductible already collected from the beneficiary; (3) Refund to the beneficiary the difference between any Part A deductible/coinsurance and Part B deductible/coinsurance; (4) Not bill observation services (G0378). The requirement that participants do not file an appeal still evokes questions, specifically whether the bar on filing an appeal prevents participants from appealing a medical necessity determination for inpatient services if they volunteer for the demonstration program.

For more information on the AB Demonstration Program or assistance with determining a hospital's eligibility to participate in the program, please contact a Wachler & Associates attorney at 248-544-0888.

OIG Releases Report Highlighting ZPIC Oversight Issues

2011-11-22T18:15:58Z

Recently, the Department of Health and Human Service's Office of Inspector General released a report which found that the workload data used by the Centers for Medicare and Medicaid Services (CMS) to oversee its Zone Program Integrity Contractors (ZPICs) were inaccurate and lacked uniformity.

The study was conducted by collecting and reviewing ZPICs' workload data related to investigations, case referrals, requests for information, and administrative actions between February 1, 2009 and October 31, 2009. The OIG only reviewed the information of the ZPICs for Zones 4 and 7 because they were the only ZPICs who had completed a full contract year at the time the study was conducted.

According to the OIG, one of the study's major objectives was to describe the extent of ZPICs' program integrity activities during the first year of operation. However, this objective went unachieved due to the inaccuracies and lack of uniformity which stemmed from system issues in CMS's Analysis, Reporting, and Tracking System (CMS ARTS), ZPIC reporting errors, ZPICs' interpretations of workload definitions, and inconsistencies in requests for information reports. The OIG also identified a number of issues inhibiting CMS from successfully overseeing ZPIC activities. The OIG has stressed that it is important that these issues are corrected so that CMS can properly analyze the ZPICs effectiveness and compare the ZPICs to their predecessors (Program Safeguard Contractors). The OIG has made a number of recommendations to CMS, which include that CMS:

Clarify the workload definition in CMS ARTS to ensure that ZPICs' workload statistics are accurate and that ZPICs report their data uniformly;
Improve oversight of ZPICs' by performing a timely review of data in CMS ARTS for each ZPIC and across ZPICs to detect any anomalies in workload reporting;
Utilize and report ZPIC workload statistics in ZPIC evaluations; and
Ensure that ZPICs have access to all data necessary to carry out their program integrity activities.

CMS has claimed that it has already complied with the OIG's first recommendation. Also, CMS concurred with the first part of the second recommendation, but it failed to concur with the second part of the second recommendation and stated that "anomalies cannot be detected across ZPICs because of the difference in fraud landscapes between ZPICs." In addition, CMS partially concurred with the OIG's third recommendation and fully concurred with the fourth.

If you have any questions relating to ZPIC audits, or need assistance in implementing an effective compliance program to protect against future ZPIC audits, please contact a Wachler & Associates attorney at 248-544-0888.

CMS to Release Comparative Billing Reports for Nerve Conduction Studies

2011-11-22T17:57:44Z

The Centers for Medicare and Medicaid Services (CMS) recently announced it will release a national provider Comparative Billing Report (CBR) addressing Nerve Conduction Studies on December 6, 2011.

The CBRs are produced by Safeguard Services under contract with CMS and will provide comparative data to help show how these individual providers compare to other providers within the same field. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. Providers should view CBRs as a tool, rather than a warning, as a way to aid them in properly complying with Medicare billing rules. It is also important to understand that CBRs do not contain patient or case-specific data, but rather only summary billing information as a method of ensuring privacy.

If you are a recipient of a CBR for Nerve Conduction Studies, or are among the other provider types that have been identified to receive CBRs (i.e. physical therapists, chiropractors, ambulance, hospice, podiatry, ordering DME and sleep studies), please contact a Wachler & Associates attorney at 248-544-0888 to discuss evaluating the CBR analysis and development of an appropriate compliance plan that will reduce audit risks.

CMS Announces Special Open Door Forum for Part A to Part B Rebilling Demonstration Program

2011-11-21T19:11:15Z

On Friday, November 18, CMS released a Q&A about the Part A to Part B Rebilling Demonstration Program. Although the Q&A does not answer many of the questions that arose from the Fact Sheet released on November 15, it does give insight into when those answers could be provided. CMS will hold two special Open Door Forums, one on November 30, 2011 and another on December 8, 2011. Both will be conducted at 2pm EST.

In addition, the Q&A announced that enrollment for the Demonstration Program will begin on December 12, 2011 at 2pm EST and some hospital facilities will be ineligible to participate in the program. For instance, facilities that receive periodic interim payments from CMS and do not participate in Medicare, will not be able to participate. In addition, psychiatric hospitals paid under the Inpatient Psychiatric Facilities Prospective Payment System, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, cancer hospitals, Critical Access Hospitals, and children's hospitals all are ineligible to participate.

Finally, the Q&A provided an email for additional questions regarding the Demonstration Program to be sent to CMS. This email is ABRebillingDemo@cms.hhs.gov.

Wachler & Associates will continue to monitor the developments of the Demonstration Program. Please contact a Wachler & Associates attorney if you have any questions regarding the Demonstration Program, including participation in the enrollment process or questions regarding the RAC appeals process.