Eliminate the ERRORS in Risk Adjustment

Help Dr. D and Natalie eliminate errors in Medicare Risk Adjustment. 

By correctly answering the questions, you can help their clinic improve the entire experience of care for their patients!  

If your up for the challenge, click on the picture above to play this quick 10 question game.

University of Miami Hospital overbilled Medicare $3.7 million, audit says

BY DANIEL CHANG
dchang@MiamiHerald.com

CARL JUSTE / MIAMI HERALD FILE

University of Miami Hospital.

The University of Miami Hospital will have to refund $3.7 million to Medicare after a federal audit of the hospital’s billing practices found the hospital overbilled in 2009 and 2010, according to a report released Tuesday by the U.S. Department of Health and Human Services Office of Inspector General.UM issued a statement Tuesday saying the university is working “with the relevant federal agencies to determine the correct amount owed for billing inaccuracies.”
In July, UMH Chief Financial Officer Darryl Caulton filed a letter contesting the inspector general’s method for calculating the refund to Medicare, saying the hospital “disagrees” with the way the figure was determined.
The federal audit covered $22.8 million in Medicare payments to the hospital for 2,194 claims that HHS officials considered “at risk’’ for billing errors. From that pool of claims, investigators randomly selected for review a sample of 200 inpatient claims for services between April 2009 and December 2010 that totaled $2.9 million in payments.
Investigators found that although the hospital complied with Medicare billing requirements for the majority of the 200 claims reviewed, 68 claims — representing $524,009 in overpayments — did not comply with agency rules.
Based on those findings, investigators extrapolated the total amount of overpayments to be approximately $3.7 million.
“Overpayments occurred primarily because the hospital did not have adequate controls to prevent incorrect billing of Medicare claims within the selected risk areas that contained errors,’’ according to the inspector general’s report.
Investigators identified the questionable claims using computer matching, data mining and analysis of inpatient claims.
According to the report, the hospital overbilled Medicare in five ways:
First, hospital administrators incorrectly billed Medicare for patient stays that should have been billed either as outpatient or outpatient with observation services.
“These errors occurred because of weaknesses in the hospital’s review process and turnover in case management leadership,” according to the report. Investigators estimated the errors caused Medicare to overpay about $448,000.
In addition, investigators found that in three cases the hospital billed Medicare separately for a patient’s discharge and readmission on the same day — even though those charges are supposed to be combined into a single claim. The three cases, between April 2009 and December 2010, caused overpayment of about $33,645, the report found.
The third type of overbilling came through use of incorrect diagnostic codes, the report said, which occurred in five of the 200 cases reviewed, and led to overpayments of $17,475.
UM hospital administrators also erred by billing Medicare for three patient discharges that should have been coded as transfers because the patients were readmitted to other hospitals the same day they were released from UM Hospital. That led to another $16,407 in overpayments, according to the report.
Lastly, HHS investigators said UM overbilled Medicare by about $8,500 for one claim because the hospital didn’t get an available credit for a replaced medical device.
According to the report, the hospital may be able to re-bill Medicare for some of the claims that were found to be overpaid.
In a six-page letter addressed to HHS auditors, Caulton, the hospital’s CFO, said the institution accepts the findings and will tighten internal controls by using an electronic quality review process. Caulton also said the hospital will improve billing controls, conduct quarterly audits of short stay accounts and place an automatic hold on Medicare claims for patients staying less than three days until the claims are released by a case manager.
But Caulton took issue with the methodology used to calculate the refund amount, and requested that HHS reconsider the sum.
He said that some of the questionable claims may be eligible for re-billing and that federal officials should not have used a sample of cases to estimate the refund amount without first resolving the re-billing question.
In the letter, Caulton noted that other audits by the inspector general “almost without exception” recommended repayment solely of the audited cases — not estimates based on a sample of claims.
“There is no reasoned basis for treating UMH differently,’’ Caulton wrote.
Donald White, a spokesman for the HHS inspector general, said extrapolation is an “extremely common” practice in determining Medicare overpayments. But he added that the refund amount is a recommendation.
The next step, White said, is for UM administrators to negotiate a repayment amount with the Center for Medicare and Medicaid Services, which administers the programs. The process usually takes 60 to 90 days, he said, but “given the government shutdown, it could be longer.”
The university bought the 560-bed former Cedars Medical Center in 2007 for $275 million. The purchase was one of several high-profile steps in the expansion of the Miller School of Medicine that included hiring more than 100 renowned researchers and creating a biotech research park to boost the school’s national profile.
The ambitious moves elevated UM’s medical school to the national stage, but they also may have seriously hampered it. In spring 2012, after suffering a $24 million loss for the first six months of that fiscal year, the medical school laid off more than 900 full- and part-time employees.
In August, UM and Jackson ratified their annual operating agreement for $102.5 million, the lowest-budgeted agreement in seven years. In the agreement, a binding letter of intent commits both institutions to multi-year exclusivity provisions for transplant, trauma, pediatrics and obstetrics services.

http://www.miamiherald.com/2013/10/08/3678166/university-of-miami-hospital-overbilled.html

Read more here: http://www.miamiherald.com/2013/10/08/v-print/3678166/university-of-miami-hospital-overbilled.html#storylink=cpy

OIG: Medicare's Recovery Audit Program Generally Accurate

Medicare's recovery audit program is more accurate than critics claim, although it could detect more fraud, according to a report by HHS' Office of Inspector General, Modern Healthcare reports.

In 2006, Congress ordered Medicare to hire four private contractors -- known as recovery auditors -- to oversee Medicare payments and find cases in which providers and suppliers were being overpaid. The auditors have encountered criticism from the hospital industry, which claims that the companies are overly aggressive. Hospitals point to hospital-reported surveys that indicate at least 40% of all payments denials are appealed and 70% of those appeals are successful. Bills in the House and Senate to temper the auditors have garnered support from the American Hospital Association.

However, HHS OIG's report found that of the 1.1 million cases in 2010 and 2011 in which an auditor recommended denying Medicare reimbursements, just 6% were ever appealed and only 44% of those appeals were successful.

The report stated that CMS is falling short on investigating the leads it receives and does not provide enough training or regular updates to help generate new fraud leads. Further, the report noted that although CMS made 28 changes to its billing rules to close "vulnerabilities" found through examination of overpayment data, the department never measured the success of those changes.

In response, CMS Administrator Marilyn Tavenner said measuring the efficacy of such changes is challenging, because some require multiple steps over long periods. She added, "Some are implemented within a few months, while others take significantly longer, hindering CMS' ability to draw conclusions about the effectiveness of a specific corrective action"(Carlson, Modern Healthcare, 9/4).

http://www.californiahealthline.org/articles/2013/9/4/oig-medicares-recovery-audit-program-more-accurate-than-believed

Lack of Medicare CPT Codes for Hospitalist Practice Creates Dilemma

The Society of Hospital Medicine is pushing Medicare to reclassify skilled-nursing facility care as inpatient care for hospitalists

by By Richard Quinn

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you're obviously going to be higher because hospitalists have a much sicker population.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

---

Richard Quinn is a freelance writer in New Jersey.

http://www.the-hospitalist.org/details/article/4954351/Lack_of_Medicare_CPT_Codes_for_Hospitalist_Practice_Creates_Dilemma.html

OIG Issues Alert Warning Physicians that They Can Be Liable for False Claims Submitted by Entities to Which They Have Reassigned Their Medicare Billing Rights

On February 8, 2012, the Office of Inspector General (OIG) issued an OIG Alert warning physicians to exercise caution when reassigning their right to bill the Medicare program. According to the Alert, “[p]hysicians who reassign their right to bill the Medicare program and receive Medicare payments by executing the CMS-855-R application may be liable for false claims submitted by entities to which they reassigned their Medicare benefits.” The OIG indicated that it had recently reached settlements with eight physicians who had allegedly violated the civil monetary penalty law by causing the submission of false claims for claims submitted to Medicare by physical medicine companies to which the physicians had reassigned their Medicare billing rights in exchange for medical directorship positions. According to the OIG, the physical medicine companies billed Medicare for services that were not actually performed or performed as billed. The physical medicine companies, using the physicians' reassigned billing numbers, falsely certified to Medicare that services performed by unlicensed physical therapy technicians had been performed or directly supervised by the physicians, when such was not the case. The Alert states that physicians have an obligation to monitor billing and other records to ensure that claims using their reassigned provider numbers are billed correctly. The OIG noted that physicians who reassign their billing rights to an entity have a right to access the entity’s billing and claim information for the services that the physicians are alleged to have performed.


Health Headlines – Editor:
Dennis M. Barry dbarry@kslaw.com +1 202 626 2959