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Posts Tagged ‘RAC / Recovery Audit Contractors’

The RAConteur: Of Robberies, RACs & the Horrors of All Things Disney

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

As we reach the Month of May, I can reflect on an April full of ups and downs.

On April 12th, my house in Milwaukee was burglarized. While on my way to work, two rank teenage amateurs smashed my son’s bedroom window, ransacked the house and took items that were mostly recovered the same day when the police in another district caught them. I have learned lessons about the attention spans of my neighbors, the price of getting a window boarded up on a Saturday and home owner’s insurance coverage. The mothers of these fine juveniles will soon receive a lesson in what we call “subrogation”.

Two days after the robbery, I found myself in Florida (one of the many lands of my nomadic youth) for this year’s AAPC National Conference. Being that it occurred in Orlando, my wife and son joined us for days at Disney World. I have thoughts to share on the slogan “Let the Memories Begin”, but I’ll hold those thoughts until later. The conference itself was one that was strangely productive as compared to those of the past.

More than anything else, as it applies to this recently-neglected space, April of 2013 became the month when the awareness of Medicaid RAC program reached critical mass. I have been a frequent guest on RACMonitor.com’s Monitor Monday RAC webinar/broadcast, and the number of questions regarding Medicaid RAC, as well as comments from affected facilities, has begun to pick up. In the interest of my entire reading population, I am going to share everything I have on Medicaid RACs right here, right now. There are still considerable gaps, so if you have any information to fill them, let me know.

Let’s begin by a little exercise in addition by subtraction. Despite the fact that the Medicaid RAC reviews were scheduled to begin nationwide on January 1, 2012, six states – Florida, Hawaii, Maryland, Oklahoma, South Dakota and Vermont – still lack a contractor. Half of these states have received what are called “time-limited exemptions” from the program, meaning that CMS’ patience for these states not having a contractor is finite.

I have no information, other than the name of the contractor, for 29 of the remaining states. For the 15 states below, information remains sketchy, but at least I have something:

Connecticut, Idaho & New York – HMS has been pursuing what they believe to be incorrect Medicaid Secondary payments for patients with Medicare as their primary insurance as part of automated review. Providers in these states who receive these repayment demands are urged to review each line item carefully, as there have been several errors in the reports that have crossed my desk.

Indiana – HMS has been going after DRGs for septicemia (416, 417, 584), OR procedures unrelated to diagnosis (468, 476, 477) Tracheostomy (482, 483, 700 with ICD-9 procedure codes 31.1 or 31.29) and claims featuring excisional debridement (procedure code 86.22). There also appears to be a focus taking shape on long term care claims, but these investigations have yet to fully emerge. Indiana providers are also urged to review each piece of Medicaid correspondence carefully, as it has been reported to me that it is somewhat problematic determining the difference between a Medicaid RAC request and one from the state’s fraud control unit.

Iowa – OptumInsight is casting a wide net. They are, at the least, currently reviewing hospital claims for stays over 2-3 days, elective c-sections, elective major bowel procedures, elective total joint replacements, spinal fusions, procedures of the uterine adnexa for non-malignancy, heart failure and shock. For the major bowel procedures, the focus appears to be falling on claims for stays of 6-9 days due to complications. Iowa Medicaid has become ruthlessly efficient in recouping funds, as they have developed a habit of doing so within 30 days of the denial letter, even if an appeal has been filed. It is also notable that Iowa offers no interest on appeals if found in the provider’s favor. Cry not, for they’ll always have ethanol as a companion boondoggle.

Kansas – HDI, a subsidiary of HMS, has been penalizing providers via automated review for patients who had an active Medicaid HMO at the time of service when straight Medicaid paid. What I have noted as “a variety of DRGs” are also being reviewed.

Michigan – I have received extensive information on Michigan’s Medicaid RAC program from two different sources in the last month. Due to an unforgiving schedule, I have yet to review the information that has been forwarded in great detail. I can tell you that HMS is looking at Medicare crossover claims for duplicate payment and overlapping inpatient stays with other facilities. Michigan has a unique request limit of a maximum of 150 records per request, not to exceed 500 records in a 3-month period.

North Carolina – HMS is extremely busy in the Tar Heel State (they must employ a larger-than-normal number of smokers). Beginning on March 1st, DRGs 191, 192, 292, 313 and 391 for short stays are under the microscope. Hospitals are warned that InterQual criteria is used for review. Ambulance claims have been on the hit list for over a year. HMS does appear to be dropping the ball on hospice claims for patients whose hospice services were billed to Medicare. HMS does not recognize that only nursing home room and board was billed as pass-through to Medicaid, which is leading to HMS reviewing the claims in question for “hospice eligibility”. North Carolina’s request limit is 300 records every 30 days.

Ohio – CGI is reviewing short stays for medical necessity. Ohio OB/GYNs  are also on the radar, as CGI is reviewing low-level established E/M services billed at the same time as pre-natal care, particularly as it applies to the usage of the -TH modifier.

Oregon – HMS is looking at credit balance reports in the Beaver State.

Pennsylvania – HMS is looking at short stays for medical necessity on the hospital side in the Keystone State.

South Carolina – Following the pattern, HMS is looking at short stays for medical necessity in South Carolina. The request limit in the Palmetto State is 150 records every 30 days.

Tennessee – HMS appears to be subcontracting work out to their subsidiary, HDI. Claims for infusion services, inpatient medical necessity and DRGs 190, 191, 193, 392, 460, 743, 847 and 951 are on the radar. Watch the dates of the Medicaid RAC correspondence carefully, as there have been cases where payments are being recouped prior to providers receiving denial information.

Texas & Virginia – HMS is in both of these states, but issues have yet to be identified to me other than the fact that both states have no limit on records requests.

Again, if anyone can fill gaps in the information vacuum, I encourage you to do so. Additionally, if any of this information appears incorrect, by all means let me know.

Finally, I’d like to conclude with some quick thoughts on Walt Disney World. It did not escape my notice that upon every overpriced contrivance up for sale in the self-styled “Magic Kingdom” lay the phrase “Let the Memories Begin”. Even in a country dripping with commerce like the United States, the idea that someone has placed a price tag on the human memory should give us pause. The simplicity of life as it presents itself to all of us is not something that requires monetary outlay. It only demands that it be shared with someone close to you. It need not include worthless bric-a-brac stamped endlessly with animated mouse ears, but rather interaction on a human level, which is something that in the end money has no power to purchase.

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May 1st, 2013 | 2 Comments »

The RAConteur: Beware of Government Geeks Bearing Gifts

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

As this space has been vacant for two weeks, I shall not bore you with the details of my absence, as it would demean us both. Instead, let’s jump right into the latest RAC-related utterance from CMS.

Since this takes effect in 5 days, I am hoping that my readers have had a chance to read CMS’ update to their medical record request limits for complex review. Since I have space to fill, I’ll provide the highlights.

First, the minimum number of requests per 45 days is being reduced from 35 to 20 for providers who have a calculated limit of 19 or less. This will be of minimal help to small rural hospitals who have been burdened by the RAC process, but when considering these types of facilities, we need to take additional facts into account. Small rural hospitals spent 3 1/2 years being abused by the RAC process to such an extent that many are operating on a financial knife-edge. The main reason for this is based on having neither adequate staffing to fight RAC determinations, nor the dollars to hire such staff. If you are in effect telling rural hospitals, “You now only have to pay us back for 20 inpatient stays every 45 days, rather than 35″, this does not fall under my definition of the word “improvement”.

The second change that is effective Monday has to do with the types of claims that can reviewed every 45 days. In a seeming compromise with hospitals facing a deluge of appeal activity for audit determinations on short stays, a Recovery Auditor may now only select a maximum of 75% of any one claim type during a 45-day period. To illustrate, if a hospital, based on its past financials, can have up to 300 claims pulled every 45 days, 225 of those could be pulled for inpatient claims, with the remaining 75 coming from any other claim type(s).

As the Trojans learned all those years ago based on their experiences with a certain wooden horse, gifts aren’t always what they seem.

It would be wonderful if a 75% cap on inpatient claims (primarily short stays) was based on the maximum number of requests per facility. Yet in the lead-up to this change, something odd was beginning to occur with some facilities. I have heard anecdotal evidence from facilities across the country who regularly appeal RAC determinations that the number of requests they have been receiving has been down from the maximum for a few months. As these stories rolled in, I chalked that up to the abrasiveness of the facilities in question with regard to RAC denials. My reasoning was that if the RACs see that they are in for a fight at certain facilities, the requests go down there and are maxed out at a hospital that won’t fight back. Thinking about this further, I may have been off the mark.

So, I am going to ask a favor of the readers. If you are at a facility who has experienced a recent downturn in ADR requests, let me know if you receive the maximum ADR request limit for your facility on any request you get after Monday, April 15th. If you have a long record of appeals, I am curious to see if the RACs were either keeping their powder dry for future battles with you or directing their cannons somewhere else.

One additional note on this CMS memo. While the minimum number of claims has moved downward, the maximum number of records that can be requested in every 45 days has not changed. It remains at 400, unless the facility has more than $100 million in annual revenue, in which case the limit is 600.

I’m always free with my opinions, so I’ll give you another one related to this latest change to the RAC process. Cosmetic surgery rarely succeeds long-term.

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April 10th, 2013 | 2 Comments »

The RAConteur: A Medicaid RAC Warning

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

Most of the industry coverage of government audits has been focused on Medicare RAC determinations, and with good reason. Nearly 40 months into the program, providers are now well aware of the substandard work product of the RAC contractors. However, the administrative costs of multi-level appeals, as well as for the provision of medical records, remain inordinately high.

On March 26th of 2012, CMS instituted a dollar maximum of $25 per medical record for reimbursement to providers forwarding requested additional documentation to a Medicare RAC contractor. This stands as the only direct remuneration to providers for the Medicare RAC process, save for any underpayments identified in audit.

The Medicaid RAC program, to put it mildly, is markedly different.

I received a comment on one of my postings from last week from one of my readers indicating that the Medicaid RAC program will not reimburse providers for medical records. Continuing the conversation offline, the reader provided me with a host of links from Medicaid RAC programs across the country stating that the contractors are not required to pay providers for medical records. This topic is distinctly absent in the Medicaid RAC Final Rule put forth by CMS.

Expanding my 24-hour search into the world of my professional contacts, it turns out the travails of this topic do not stop with the RAC program. Medicaid Integrity Contractors (MIC) are also not mandated to reimburse providers for medical records.

The prevailing argument that has been brought to my attention in multiple states is that the payment for provision of provider records for any Medicaid audit is included in the provider’s reimbursement for the original service billed.

With this information in hand, we need to take a step back and compare the Medicare and Medicaid RAC programs side by side. For the Medicare RACs, CMS sets the documentation request limits for all contractors. On the Medicaid side, it is much different. The Medicaid RAC Final Rule left it up to the states to determine the limits to documentation requests for providers. In addition, unlike the Medicare RAC program, Medicaid RAC contractors are not required to publish an approved issues list.

Just for kicks (because I’m just that kind of guy), I’ll throw out something else to think about. CMS was very clear at the beginning of the Medicare RAC program that if physician E/M services were to be audited, professional societies (such as the AMA) would be notified. I find no such language in the Medicaid RAC Final Rule. I now ask the reader to draw his or her own conclusion to that information.

It may be the most poorly kept secret in the world that Medicaid reimbursement is the worst of all major insurance carriers. The situation we are faced with right at this moment can be summed up in one sentence. Medicaid pays the provider community poorly, the payment includes the cost of sending records to any Medicaid audit entity, on the cusp of these audits, as well as the Medicaid population nationwide, expanding, and short of dropping out of your state’s Medicaid plan, there is nothing you can do about it.

Even if a provider has seen no Medicaid RAC activity as of yet, I must insist that the Medicaid RAC Statement of Work in your state be reviewed thoroughly. Know your RAC contractor, and begin a dialogue. Familiarize yourself with the Medicaid appeals processes in your state, as based on the provider-friendly overturn rates of the Medicare RAC program, mistakes will be many and often.

Most importantly, track the costs of providing records to audit entities and compare them to the reimbursement of the services audited for your Medicaid patients. If the two numbers are very close to each other, I would say that you, as an affected provider, have a very important decision to make regarding continuing participation in your state’s Medicaid program.

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February 20th, 2013 | 2 Comments »

The RAConteur: The Latest RAC Report to Congress

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

If there is one thing I can’t stand in the world of journalism, it is the alarming trend toward a lack of detail. Journalism is not about stenography. In a country with a “free press”, we must rely on people to not simply accept what they are being told. Journalists have a mandate to discover and report. They should look at the world with the eyes of Magellan, continuing to explore, challenge and report.

Recently, CMS released its Fiscal Year 2011 Report to Congress on Recovery Auditor Activity. Most of the press releases I have seen talk about the numbers, as if the only pages of the 41-page report that were reviewed were the two that dealt with collections and appeal numbers. None of these are remotely believable, let alone finalized, so I am going to ignore them. I feel it is important to look and read the entire report for findings that point to the continuing failure of the program.

The first thing that jumped out at me was on page 7. Under the heading of “How Recovery Auditors are Paid”. Like virtually everyone else who has wide exposure to the program, I was aware of the base contingency fee of 9 to 12.5 percent for the permanent contractors, but what I was unaware of was that this applies to all claim types except those for durable medical equipment (DME). The contingency fees for DME claims range from 14 to 17.5 percent.

This fact requires all of us to stop and think for a moment. One of the biggest areas of fraud in the Medicare program, which has been reiterated over several years and hundreds of OIG police blotters, is DME. Similarly, service specific probes undertaken by the MACs of DME claims have consistently reported inordinately high DME error rates. Seeing this, CMS has incentivized the RACs to go after improperly paid DME claims retrospectively with a 5% premium on the contingency fees.

If the current approved issues listings of the four RAC contractors are to be believed, this incentivization is being met with indifference. The approved issues lists are still made up of an overwhelming majority of inpatient hospital issues. HDI, the Region D contractor, currently ranks highest with 29 DME issues, while Connolly in Region C  brings up the rear with a mere 11. This is in contrast with CMS’ statement on page 18 that says “The CMS also continues to encourage Recovery Auditors to review all claim types”. Apparently, the RACs didn’t get the message about follow-through.

Perhaps the biggest outrage can be found on page 36 of the report. This is the page that shows the cumulative accuracy scores for the four recovery auditors. If we remember, the FY2010 Congressional Report had accuracy scores of 97.6 to 99.4 percent. What we knew at the time of the release of that report that these numbers strained all sense of credibility. Knowing that the number of outstanding appeals of RAC determinations number well into the hundreds of thousands now, the information on page 36 provides little solace. It is at least notable that the accuracy scores have gone down for every single Medicare RAC contractor, but the scores remain in an unbelievable range of 90.7 to 98.4 percent. CMS at least added information regarding how many claims were reviewed, with a post-script to the numbers stating “The sample size reviewed for each Recovery Auditor was between 1275 and 1300 claims”. Based on the fact that any one hospital that receives more than $100 million in payments annually from Medicare can receive as many as 4,867 additional documentation requests for complex review in a year, the claim sample size appears to be paltry in comparison.

The types of claims audited, as well as the entity that is conducting the reviews, was left out of the report. I asked CMS if the RAC Validation Contractor (RVC) was the entity performing the audits to determine the accuracy scores, as well as who is if the RVC is not. As of the release of this posting, I had yet to receive an answer to my question from CMS.

At the end of the day, the problem is not with the report, but the fact that only CMS submits a report to Congress. The more accurate reporting of RAC activity is coming from the AHA in their quarterly RACTrac report. Rather than CMS doing all of the talking on Capitol Hill, I suggest that the AHA get into the habit of sending their quarterly report to every member of Congress to counter CMS’ rosy picture of the program. There isn’t a single government entity that has ever existed that regularly admits to its own shortcomings. In a free society, it is left up to those of us who bother to discover, challenge and report. Despite being long separated by time and progress from Magellan, that process should never end.

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February 14th, 2013 | 1 Comment »

The RAConteur: Another Set of Gross Numbers

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

There is something about the American Public that reflexively loves achievement. As a group, we love a winner, especially if there is an inspiring back story. Part of the reason that we all fell for Lance Armstrong was the fact that he had been a cancer survivor.

Yet it takes quite a bit of hubris to cheat death and then follow it up by cheating at life. Now when ol’ Lance tries to play the cancer card to explain his actions, it rings hollow as an excuse for his less-than-savory post-illness behavior.

When the Recovery Audit Program was introduced, it was sold as a way to return improperly paid dollars to the Medicare program. The auditors would be considered as the good guys, because the end result would be the long-term sustainability of the Medicare program based on the millions of dollars returned. It represented the perfect pairing of our love for a good back story that also helps people far into the future. How could this possibly go wrong?

CMS recently released their latest quarterly report of RAC recoveries. We are now 13 quarters into the permanent program, and we have learned that these numbers amount to nothing more than a chest-beating gross, rather than a quantifiable net.

Health care websites are all abuzz with the fact that the RAC identified nearly $780 million dollars in improper payments in the first quarter of Fiscal Year 2013. As has been the standard, CMS did not put forth numbers regarding the number of claims currently being appealed, the number of claims per Medicare appeal level or the appeal success rate for providers. It would appear that the numbers put forth by CMS are gross in more ways than one.

With all of this in mind, I suggest the following course of action when CMS wants to beat their chest with patently false numbers such as what has just been released. Print out the newsletter, get a camera, hold the newsletter up to the camera, talk about what it is and then shred it while being filmed. After shredding the document, look straight into the camera and say “CMS, tell us the truth”. Once you have done this, post it to YouTube with the title “CMS RAC Myths”.

Public perception of a negative being a positive happens only because of an information vacuum. If the public learns about the administrative burdens that hospitals are experiencing simply to protect revenue from medical care provided long ago, perhaps the perception changes.

With the death by committee of the Medicare Audit Improvement Act of 2012, Congressional action on RAC abuses seems to be falling victim to other budgetary “priorities”. It is left to the grassroots to shine a light on the fact that the statements of billions of dollars returned to the program since the inception of the permanent program is a deliberate exercise in deception.

If you want some numbers that are closer to the truth, wait for three to four weeks for the latest AHA RACTrac data to be released. At the very least, it presents reliable appeal numbers, something CMS hasn’t done in any reliable fashion. We all love achievement, but as we have learned lately in the case of Lance Armstrong, it is best to achieve honestly.

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January 30th, 2013 | 1 Comment »

The RAConteur: Incorrect Thoughts & Impressions

Posted by J. Paul Spencer, CPC, CPC-H in RAC / Recovery Audit Contractors

As good as we all think we are, as shiny as our shoes appear and as much as we all believe we possess wisdom, we are all human and we make mistakes.

All along, I have been under the impression that the RAC contractors were mandated to conduct provider outreach for claims issues. Believing this to be the case, I even stated this in a public forum yesterday. I thank the people in that forum for stating that the RACs conduct provider outreach only to explain their “purpose and direction”. Outreach on claims and payment issues must be done by the MACs. My thanks to the people in that forum for the correction. In order to avoid confusing people further, my thoughts on the subject were deleted from said forum by my own hand.

Because many of us in the administrative side of health care have now been knee-deep in the RAC process for over three years, the minutiae of the program is certain to be know by someone, as I have learned. For the balance of the country, all they are hearing from CMS is the gross number of dollars identified as improperly paid by Medicare. What is not being accurately reported are appeal rates, appeal success rates, the level at which most of the successful provider appeals are occurring and – most importantly – the net amount that has been identified by the recovery auditors.

The public is being left with the impression that private contractors are identifying government mistakes. What they are actually doing is shining a light on the cockamamie payment methodologies for hospital services put forth by CMS and the circular logic the MACs use to defend the same. I remind the reader that this is being done with the idea that the monies returned to Medicare will fund health care reform. That, perhaps, is the ultimate false impression and the worst form of mistake.

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January 23rd, 2013 | No Comments »

The RAConteur: The Death of Improvement

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

After another week on the road in an undisclosed location, I return to my desk, separate the papers, prioritize the many projects coming up over the next few months, and bring the reader a brief RAC program update.

I appeared on Monitor Monday this past Monday (hence the name). During the final “roundtable” segment, one listener asked about the status of the Medicare Audit Improvement Act of 2012. I commented that there were co-sponsors that had since left the House of Representatives, but it actually goes further.

According to the Govtrack website, the bill was introduced on October 16, 2012. It was subsequently referred to the House Energy and Commerce Committee, as well as the House Ways and Means Committee. Due to the fact that there was no action taken on the bill before the end of the congressional session, the bill has officially died in committee. The bill lived for only 79 days. So long, we hardly knew ye.

The original sponsor of the bill, Sam Graves, who represents the 6th Congressional District in Missouri, remains in Congress. I would have liked to have contacted him and discussed whether the bill would be re-introduced in the current Congressional session, but because I don’t live in the northern 1/3 of Missouri, I can’t guarantee that I would ever get an answer.

With that in mind, I’d like to release a challenge to my readers. If you happen to live and enjoy the nightlife in Saint Joseph, if you know the roads of Green City, or if you happen to know someone who cruises the neighborhoods of Chula, have you or some “Show-Me-Stater” that you know contact Representative Graves and ask whether the bill will be re-introduced. In the spirit of Milwaukee, the first one to get a clear answer gets a free drink from yours truly (as soon as we meet face-to-face).

In the vacuum created by a lack of Congressional action, CMS is attempting to fill the void of information about the RAC program with news releases and memos that can best be described as self-serving distortions. If CMS is controlling the dialogue, the ongoing damage being put forth by the RACs on the provider community will continue unabated. We can either sit here as a group, commiserating and sharing experiences, or we can fight. Many RAC coordinators have reached the end of their rope and are primed to fight. Let’s start the fight with Congressman Graves.

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January 16th, 2013 | No Comments »

Sneaking Things In While I Am Out of the Country

Posted by J. Paul Spencer, CPC, CPC-H in Health Care Reform

I returned to work yesterday after a six-day sojourn in search of hockey. After driving 260 miles deep into Canada and back, I can say that I saw some amazing hockey and met some great people. I also saw Union Station in Toronto on New Year’s Eve, which you will all have to ask me about privately.

While I was unpacking my suitcase, Congress passed something called the American Taxpayer Relief Act of 2012. We already know the obvious result of this, as physicians did not see their reimbursement drop 26.5%, with hospital cuts making up the difference, but two sections that caught my attention appear consecutively on page 45 of the final bill.

In Section 638, a section titled “Removing Obstacles to Collection of Overpayments”, CMS can now go back 5 years, rather than three, to collect overpayments. The estimate is that this change will bring in an additional $500 million dollars or revenue.

This passage certainly raised the ire of RAC coordinators nationwide. CMS has been painting a false picture of the results of the RAC program by cherry-picking numbers and declaring RAC shortcomings as “myths“. In a late-night coup, CMS now gets to go back two more years to attempt to yank reinvested dollars from physicians and hospitals.

What is not getting sufficient attention is Section 639, which is going to increase the risk adjustment percentage paid to Medicare Advantage. I have covered in some detail in the past about how Risk Adjustment Validation audits have revealed that the Medicare Advantage carriers have been stretching the truth about the acuity of illnesses of their population. The reward for their behavior, aside from continuing Medicare Part C to the tune of billions of dollars, is a raise in the risk adjustment, which most times are found to be incorrect.

The idea of a “fiscal cliff” was nothing more than a deflection. For six weeks we heard about “the American taxpayer”, as if we had some kind of choice in the matter as to what would happen next. What actually occurred, based solely on Section 639, was that taxpayers got no relief and insurance companies bellied up to the trough for more money from our pockets.

I met some great people in Canada who were not shy about sharing with me what they thought about our political system. I also found out that I really like small-town hockey, Tim Horton’s donuts and the food dispensed by the Pizza Pizza chain. If while living here, I am going to be continually lied to about how our health care dollars are being spent, perhaps it is time to follow the lead of Congress and place my patriotism up for sale to the highest bidder.

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January 4th, 2013 | 2 Comments »

The RAConteur: Lacking Patience For Sloppy Work

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

This year’s Christmas was somewhat bittersweet for me.

My family made sure that I received gifts spanning both desire and much-needed utility, but one bit of news arrived over the wire services that put a damper on the festivities.

Jack Klugman, one of my favorite character actors, died on Monday at the age of 90. The obituaries that have been written over the last two days talk mostly about his Emmy Award-winning turn on “The Odd Couple” TV series, but for me, Jack Klugman will always be known for Quincy, M. E.

Looking at this show on DVD (I have three seasons at home) through the lens of 2012, this show seems like the height of camp, with a coroner running out righting wrongs and solving crimes at the drop of a hat when most coroners are glued to a stool over corpses. I do believe that it says something about my personality as an adult that when most kids my age (10-17 at the time it actually aired on NBC) were watching a string of stupid TV shows like Happy Days, I was watching Quincy.

However, when I break it down for my family and friends, I tell them that every tool I need for life, I learned from Quincy. Klugman’s protagonist would fight to the death for a cause that he believed in. In one case, fiction spilled into real life, as Klugman helped usher in the Orphan Drug Act in 1983 as an actual piece of legislation. Quincy would also always use science as a means to an end, which I am much more likely to do as an adult who lives free of organized religion.

Yet the most important thing that Quincy taught me was to have a short fuse for sloppy work. The “doctor without a first name” would spend a few episodes a year conducting secondary autopsies to find things that weren’t found by the first coroner, infuriating and shaming his colleagues, but ultimately getting at the truth. I carry this with me, and in this space, I carry anger and a particularly large chip on my shoulder for the RAC program in particular.

We are now a little over three years into the permanent program, and the RAC work product remains sloppy, inadequately substantiated and poorly executed. The provider community continues to be burdened by government contractors who are only familiar with CMS guidelines in passing. With regard to the RACs, they continue to focus on short stays at hospitals, which is nothing more than exploitation of a CMS guideline that is full of holes and poorly explained.

While I am on the subject of sloppy work product, I would be remiss if I didn’t mention the RAC validation contractor, Provider Resources, Inc. of Erie, PA. There is a severe disconnect between what PRI has stated about the accuracy of the four RAC contractors, and the information we are getting from the AHA on a quarterly basis as part of their RACTrac survey. Two federal fiscal years have passed since the last RAC report to Congress, but on the 39th and final page of that report, the RAC validation contractor’s accuracy scores for each individual RAC were listed. The average accuracy score was just under 99%. In CMS’ eyes, thanks to what could only be a shoddy method of determining RAC contractor accuracy, the RACs are doing an incredibly accurate job. In the eyes of hospital RAC coordinators nationwide, these numbers are high comedy and can be summarily dismissed.

If I could live my life exactly like Dr. Quincy, I would be bursting into offices one by one, raising my voice just below a scream, making wild arm motions and hand gestures and telling select employees of CMS and their contractors that what they are offering as “the best” isn’t good enough. It’s sloppy, underhanded, statistically questionable and threatens to create a health care system where the type of care being applied could be scientifically invalid based on some twisted theory about how facilities should be paid for the care of the sick.

As it stands, I’ll continue to use this space to call the RACs out on their methods, and my friends and family will continue to cringe whenever an incoming call comes into my cell phone, setting off the theme song to Quincy, M. E. as my ringtone.

The Fi-Med blog will be silent until Friday, January 4th as its writer goes on a week-long journey into Michigan and Canada in search of ice hockey.

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December 26th, 2012 | No Comments »

The RAConteur: Whose Myths are These?

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

There is a famous political quote from the late former New York Senator Daniel Moynihan, who stated “You’re entitled to your own opinion, but you’re not entitled to your own facts”. When I watch what passes for news nowadays, I tend to think Senator Moynihan was ahead of his time.

While I usually cover non-audit health care issues on Fridays, CMS released a document this past Monday that was so riddled with self-pity and abbreviated clarifications, it must have been written by a 4-year-old.

The title of the document is “Medicare Fee-For Service Recovery Audit Program Myths”. The document contains 14 so-called myths, but at least half are issues that I have never heard raised by a reputable source, and the remainder appear to be the incomplete thoughts one would expect from someone currently between lithium refills. My jaw ended up hanging so far beneath my face at the conclusion of these four pages that nothing short of a point-by-point rebuttal is warranted. Without further ado, we begin:

Myth 1 – RACs deny every claim that they review- I have never heard anyone make this claim, though I am sure that some hospitals feel this way based on the way RACs tend to hyper-focus on some facilities in the same way that armed robbers look at unarmed urban liquor stores. CMS goes into a tortured explanation of the CERT study to refute this, but the explanation ends up going nowhere. The Part They Left Out: According to the AHA, two-thirds of all RAC documentation requests do not lead to the determination of an improper payment. Duck-hunting in the dark offers a better accuracy percentage than this.

Myth 2 – RACs have a contingency fee between 30 and 50 percent – Anyone who had this perception would have been so far separated from the RAC Statement of Work that it would be quite obvious that they have no day-to-day contact with the RAC program and its process. The Part They Left Out: While the RACs are paid on a contingency fee basis (up to 12.5% at the high end for CGI), the rest of the integrity contractors (MIC, ZPIC) are paid flat fee contracts for a fixed time period, and their rate of success is actually worse than the RACs.

Myth 3 – Every RAC denial is overturned on appeal - To prove that this is false, CMS provides appeal data from FY 2010, seemingly forgetting that we are currently in FY 2013 and that according to the AHA, more than 71% of all appeals filed by their RACTrac participating hospitals have yet to be finalized. Of the ones that have, hospitals are winning 3/4 of the time. CMS has responded to this success rate by attempting to eliminate the ALJ level of appeal, where most of their losses are occurring. The Part They Left Out: Remembering that over 40% of all RAC determinations are appealed, CMS’ elucidation of this “myth” appears rather combative.

Myth 4 – RACs have non-clinicians conduct review of medical records – The response to this “myth” is classic deflection. The memo states “Fact: Each RAC employs certified coders, nurses, therapists and a physician contractor medical director (CMD)”. The last time I checked, clinical decisions are made by doctors, with nurses and therapists defined as “ancillary providers” and coders defined as “those people who tell me I’m billing something wrong”. Unless the lone CMD at each contractor, armed with candy dispensers full of Dexedrine and crystal meth, has a hand in every RAC determination, then the fact that non-clinicians are conducting review of medical records is not a myth! The Part They Left Out: CMS goes on to state that a RAC org chart is submitted “as part of the proposal and identifies the number of key personnel and the organizational structure of the [RAC] effort”. These charts were not offered as an addendum to this memo, so the “myth” actually stands as fact, given that the ratio of employees for each RAC remains a mystery to the provider community.

Myth 5 – RACs create their own policies and are not bound by CMS regulations, NCDs or LCDs – Again, no one dealing with the RAC process ever made this claim. The claims that they are actually making, particularly as it applies to the enormous number of denials for short stays, is that the CMS regulations are poorly written and inadequately clarified. Additionally, the MACs, whenever they make an attempt at clarification, have clouded key issues to such a degree that they can’t answer provider inquiries regarding past guidance they have provided. The problem has gotten so bad that NGS, an affected MAC, won’t allow any recording of their teleconferences based on past embarrassments. The Part They Left Out: The ALJs seem to have a good grasp of the issues involved, but because they more often find in favor of providers, CMS’ game plan, as stated previously, is to take them out of the game.

Myth 6 – RACs can review as many claims as they want from a provider – CMS goes on to state that the maximum number of requests per 45 days is 400. Actually, providers with over $100 million in payments can have up to 600 charts requested every 45 days, based on the ADR limit update effective on March 15, 2012. The Part They Left Out: CMS conveniently ignores semi-automated review in addressing this issue, as there is no limit to the number of claims that can be selected under semi-automated review. Hence, RACs indeed can review as many claims as they want from a provider, making this CMS myth (you guessed it) a non-myth.

Myth 7 – RACs don’t have physicians on staff – If you exclude the one solitary CMD strung out on stimulants, then yes, the RACs don’t have physicians on staff conducting complex reviews. While we’re on this topic, I think it’s worth questioning the motives of any physician, nurse, therapist or coder who makes it their life’s work to make the lives of hospitals a Hell on Earth with their activities. Is this really what you want to do for a living? As a certified coder, anyone with credentials similar to mine who is working for a RAC isn’t trying very hard to build a career in my opinion. The best people who happen to find themselves under the umbrella of these organizations eventually leave, partly because that identified as “fraud” is usually CMS-induced ignorance  (see notes under Myth 5) and partly due to wanting to have their souls cleansed and in good repair as life’s end draws near. The Part They Left Out: RACs have been going after hospitals primarily, but when Part B claims are reviewed, I would say that the odds of a specialist having their clinical documentation reviewed by a physician of the same specialty are practically nil, making appeals virtually automatic.

Myth 8 – RACs are focusing complex reviews on Critical Access Hospital claims – CMS goes on to state that “Recovery Auditors have not completed any complex reviews on Critical Access Hospital claims”. The automated reviews continue, and who knows whether any semi-automated reviews have been conducted? I would say that this statement of “myth” is perhaps best described as a half-truth. The Part They Left Out:  I appeared on a broadcast of Monitor Monday back in September where the administrator from Pushmataha Hospital in Oklahoma related that he had elevated his complaints to his congressperson, as Connolly was picking them apart financially. In addition, he is having to go to his community and beg for tax increases because he can’t get funding to keep his doors open. If a rural population being served by a hospital is threatened by RAC activity, it matters not that they lack the imprimatur of the CAH designation. It means that care for an under-served population is being threatened just so someone can wave poorly-estimated RAC dollar results in all of our faces to pound their chests about how they are funding health care reform.

Myth 9 – RACs do not tell anyone what they are reviewing – Anyone connected with the RAC program knows that there is an approved issues list on the RAC websites. This is yet another example of a myth that no one has profligated. The Part They Left Out: Medicaid RACs are not required to provide approved issues listings for the audits they are conducting, so when it comes to Medicaid, it is indeed true that the RACs do not tell anyone what they are reviewing.

Myth 10 – RACs do not issues (sic) detailed results letters – I’d like to pause to state that the garbled word usage in this myth, along with the appearance of the word “rational” in explaining myth 9, where the word “rationale” would have been more appropriate, tells me that this whole memo was a panicked rush job. With regard to this myth, The results letters I have been made aware of do not go into dramatic detail, but rather contain “canned” language from a template explaining a general reason for a claim denial based on the approved issue being applied. The Part They Left Out: If you are ever able to have a conversation with the actual reviewer of your documentation who retroactively denied your claim, consider yourself lucky.

Myth 11 –  RACs do not issue timely denial letters – This is actually not a myth. The MACs took over the process of issuing demand letters back in January, and the timely issuance of letters has been an ongoing issue for most of 2012. The Part They Left Out: CMS lists this issue as a myth, but in the ensuing paragraphs beneath it, they do not refute it, but rather use twisted language about the importance of timely issuance based on appeal time lines. There are some RAC claims that have been in the appeals process for over two years and have only reached level 3 out of 5, so I think it best that CMS not descend into pontification about the importance of appeal time lines.

Myth 12 – RACs outsource all the medical review to staff in India and the Philippines - Again this is the first that I have heard of this, so this is actually a myth. The Part They Left Out: PRGX is a RAC subcontractor here in Region B. They have subcontractor status because the quality of their work product was sub-par during the demonstration project. Region B has the highest appeal overturn percentage, and I am sure that a number of those issues can be traced to the subcontractor rather than CGI. Maybe outsourcing overseas would provide a better result than an entrenched government contractor who fought the permanent RAC awards? A man can dream.

Myth 13 - RACs deny Inpatient Rehab Facility claims because the care could have been given in a less intensive setting - CMS does not refute this in subsequent paragraphs. They only explain the rationale for such denials. Remember kids, it’s only a myth when someone says three little words: “that’s not true”. The Part They Left Out: Whenever I hear the word “rehab”, I immediately think of my colleague Nancy Beckley, an expert on the subject. In a brief phone call today, she reminded me of the widespread denials for IRFs that occurred during the RAC Demonstration Project related to joint replacements being “not medically necessary” for stays. Every one of these denials was reversed on appeal, and the contractor, (wait for it) PRG Schultz, now known as (you guessed it) PRGX was “penalized” into subcontractor status. Not surprisingly, the issue of joint replacements being not medically necessary is rearing its head again, so expect this “myth” to soon come true in spades.

Myth 14 – RACs target providers who are part of CMS demonstrations – CMS explains that any hospital can be targeted, but I have heard anecdotal evidence that strongly suggests that hospitals who entered into demonstration projects and then exited (more than likely because they wanted their appeal rights back that were negated by participation in the demonstration) suddenly and mysteriously see a jump in ADR requests. The Part They Left Out: RACs are ripping the daylights out of hospitals, but physicians and DME suppliers (!!) are getting all but a free pass, based on current issues lists. We are now three full years into the permanent RAC program. It certainly appears to me as if the RACs continue to focus their work on the claims with the highest dollars, rather than the claims with the highest error rates. I would call that “targeting”.

Perhaps the late Senator Moynihan’s quote could be sligthly altered in this case to read, “You are entitled to your own opinions, but you are not entitled to your own facts, and based on your lousy facts, I find what you proudly label ‘myths’ to be highly questionable as well”.

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December 21st, 2012 | 3 Comments »

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