On November 17th, Donald Berwick testified before the Senate Finance Committee. As you can imagine, there was a lot of political tension surrounding this event.
The video of the entire senate hearing is here: http://finance.senate.gov/hearings/watch/?id=280ebc81-5056-a032-5254-1010c1e9b945
Berwick's prepared statement can be found here: http://finance.senate.gov/imo/media/doc/FINAL%20Donald%20Berwick%20Testimony%2011.15.101.pdf
Bacus' prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/11172010%20Baucus%20Hearing%20Statement%20Regarding%20New%20Patient%20Protections%20to%20Strengthen%20Medicare%20and%20Medicaid1.pdf
Grassley's prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/health%20care%2011-17-10%20hearing%20with%20Dr.pdf
Kaiser Health News, a program of the Kaiser Family Foundation, consolidated a resource page about Dr. Donald Berwick. It contains both what he has said as well as what others have said about him (and what he said). It can be found here: http://www.kaiserhealthnews.org/Stories/2010/June/30/Donald-Berwick-Resource-Guide.aspx
Showing posts with label Fraud. Show all posts
Showing posts with label Fraud. Show all posts
Sunday, November 28, 2010
Tuesday, November 9, 2010
RAC for Medicaid?
The following is a press release from CMS (Nov 5, 2010) announcing some of the details for the implementation of Medicaid RAC. Items of interest to quality professionals are in red.
MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS
CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM
The Centers for Medicare & Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act’s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.
“Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,” said CMS Administrator Donald Berwick, M.D. “We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.”
Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.
Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments.
CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.
Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.
Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled “Medicaid RACs: Are You Ready?” targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS’s experience with Medicare RACs.
A copy of the regulation may be viewed at the Federal Register’s website, http://www.ofr.gov/inspection.aspx. For Additional information on the Affordable Care Act can be accessed at, http://www.healthcare.gov/.
MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS
CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM
The Centers for Medicare & Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act’s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.
“Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,” said CMS Administrator Donald Berwick, M.D. “We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.”
Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.
Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments.
CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.
Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.
Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled “Medicaid RACs: Are You Ready?” targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS’s experience with Medicare RACs.
A copy of the regulation may be viewed at the Federal Register’s website, http://www.ofr.gov/inspection.aspx. For Additional information on the Affordable Care Act can be accessed at, http://www.healthcare.gov/.
Wednesday, December 2, 2009
New RAC Rules for Document Request Limits
Yesterday, CMS updated its rules regarding limits on the number of additional documentation requests. Excerpts from the document has been cut and pasted below.
You can download the original document at:http://www.cms.hhs.gov/RAC/Downloads/DRGvalidationADRlimitforFY2010.pdf
You can find the RAC homepage at: http://www.cms.hhs.gov/RAC/
Additional Documentation Limits for FY 2010 for DRG Validation
as of December 1, 2009 (Excerpts)
You can download the original document at:http://www.cms.hhs.gov/RAC/Downloads/DRGvalidationADRlimitforFY2010.pdf
You can find the RAC homepage at: http://www.cms.hhs.gov/RAC/
Additional Documentation Limits for FY 2010 for DRG Validation
as of December 1, 2009 (Excerpts)
- CMS has modified the additional documentation request limits for the RAC program in FY 2010. These limits will be set by each RAC (CMS) on an annual basis to establish a cap per campus on the maximum number of medical records that may be requested per 45-day period.
- A campus unit (defined below) may consist of one or more separate facilities/practices under a single organizational umbrella; each limit will be based on that unit’s prior fiscal year Medicare claims volume.
- Limits will be based on the servicing provider/supplier’s Tax Identification Number (TIN) and the first three positions of the ZIP code where they are physically located.
- Limits will be set at 1% of all claims submitted for the previous calendar year (2008), divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days. A provider’s limit will be applied across all claim types, including professional services. Note: FY 2010 limits are based on submitted claims, irrespective of paid/denied status and/or individual lines, although interim/final bills and RAPs/final claims shall be considered as a unit.
- While respecting a provider’s overall limit, the RAC may exercise discretion in the exact composition of an additional documentation request. For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may only be a small portion of their total claim volume.
- Two caps will exist in FY 2010: Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare (per TIN, across all claims processing contractors) will have a cap of 300 additional documentation requests per campus unit, per 45 days.
- In addition, in FY 2010 CMS will allow the RACs to request permission to exceed the cap. Permission to exceed the cap cannot be requested in the first six (6) months of the fiscal year. The expanded cap will not be automatic; the RACs must request approval from CMS on a case-by-case basis and affected providers will be notified prior to receiving additional requests.
Thursday, June 25, 2009
CMS updates RAC Schedule
CMS released an updated schedule of RAC roll out. The updated schedule can be found here: http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf
Note that Indiana is considered a yellow/green state.
Note that Indiana is considered a yellow/green state.
Medicare Fraud Strike Force Hits Detroit
HHS issued a press release on 6/24/09 detailing the arrests of 53 physicians and healthcare executives. You can find the complete release at: http://www.hhs.gov/news/press/2009pres/06/20090624a.html
Excerpts:
Excerpts:
Today, federal agents from the FBI and the HHS Office of Inspector General
(HHS-OIG) began executing arrest warrants in Detroit, Miami and Denver as part
of a concentrated effort to address fraud in the metro-Detroit area. Charges
were unsealed today against 53 individuals who are accused of various Medicare
fraud offenses, including conspiracy to defraud the Medicare program, criminal
false claims and violations of the anti-kickback statutes. The Strike Force
operations in Detroit have identified two primary areas – infusion therapy and
physical/occupational therapy providers – in which schemes were allegedly
orchestrated to defraud the Medicare program.
According to the indictments, the defendants charged today participated in
schemes to submit claims to Medicare for treatments that were in fact medically
unnecessary and oftentimes, never provided. In many cases, indictments
allege that beneficiaries accepted cash kickbacks in return for allowing
providers to submit forms saying they had received the unnecessary and not
provided treatments. Collectively, the physicians, medical assistants,
patients, company owners and executives charged in the indictments are accused
of conspiring to submit more than $50 million in false claims to the Medicare
program.
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