I bid you welcome to my day off.

At long last, my 3-year-old son, whose preschool is closed today, has settled down for a nap just long enough for me to turn my attention to this humble little corner of the world wide web. With the help of Brian Wilson’s Smile at half-volume in my mp3 player, I now ready myself to bring you the weekly update in the wacky, wonderful world of American health care. As you will see in the succeeding paragraphs, the phrase “promote the general welfare” as it appears in the U. S. Constitution has been on an odd road as of late.

In last week’s post, I spent some time going over the issues most often faced on the patient side of the health care delivery system in the health care overhaul. As we dig deeper into the Patient Protection and Affordable Healthcare Act, it appears that the provider community is about to enter a world of scrutiny and forced conversion unlike any we have seen since the dawn of the government’s role in health care.

Beginning with Medicare basics, retroactive to January 1, 2010, providers will now face a 12-month filing deadline from the date of service for claims to Medicare for reimbursement. Any dates of service prior to January 1, 2010 will need to be submitted to Medicare by December 31st of this year. Claims that do not will face timely filing denials.

As if doctors didn’t have enough to worry about in the current climate of fraud and abuse investigation, the new law has decided to put the current process on a diet of steroids and gun powder. The existing Medicaid Integrity Program appears about to either be strengthened or usurped by Recovery Audit Contractors in every state tasked with discovering overpayments and underpayments specifically from Medicaid. On the national side, the existing RAC’s will be expanding their investigations to include Medicare Advantage plans and drugs dispensed under Medicare Part D. As the RAC’s are independent contractors, and are rewarded a portion of any recovery gained as a result of investigation, it’s safe to say that providers shouldn’t expect a lot of checks for discovered underpayments in this new environment.

As if the investigations of claims wasn’t enough to give providers an Orwellian sense of paranoia, the Medicare enrollment and revalidation process is about to change in a similar manner. New providers and re-enrollees will now be subject to an enhanced screening process yet to be devised by the Department of Health & Human Services and the Office of Inspector General. It will include at least a check of the provider’s medical license. If OIG and HHS considers a particular provider to be an increased risk to the program, the provider could be subject to fingerprinting, criminal background checks and unannounced visits to the provider’s site of service.

When it comes to overpayments, any overpayment from Medicare discovered by the provider or their billing entity must now be returned to  Medicare within 60 days.

It’s a good time to take a step back and review the current landscape. In the next 5 years, interoperable electronic medical records, ICD-10, e-prescribing and quality reporting will slowly become mandatory for all medical professionals. If as a provider you have yet to explore any of these issues, now would be almost be too late of a time to start. As for myself, in order to have the physical and mental energy to deal with all of this in an advisory capacity, I’m going to take Brian Wilson’s advice; I’m gonna chow down my vegetables.

1:25 pm, April 2nd, 2010 |