Reimbursement Rocks

CMS (The Center for Medicare and Medicaid Services) recently released a report stating that Medicare has recovered more than $1 billion through the Recovery Audit Contractor (RAC) program since 2005, with 85 percent of the money having been taken back from hospitals. When the costs of collecting the money were taken into account–along with the small number of refunds made to providers–CMS was able to return $693.6 million to the Medicare trust fund. Not bad we may say…good for us as tax payers! Recoup from the evil hospitals…they didn’t need it anyway. But what about the rest of us?? How will (or did) this affect us?

In its analysis, CMS said that most of the improper payments made to providers occurred due to billing and coding errors, frequently when one procedure was billed repeatedly. Other problems discovered by RACs included incorrect procedure codes and submission of duplicate claims that both got paid. When the RACs challenged Medicare payments, 14 percent of providers appealed, and 4.6 percent of those decisions were overturned.

The first call I made when I read this was to my good buddy, John Davila, DC, a partner and VP at Compliant Services and Solutions. He’s the master blaster of compliance and who I defer to on such issues. (and I recommend that that my clients do too!) “So, John,” said I, “what was the first thing you thought when you read this?”. Inquiring minds want to know, and that certainly included me! I knew he would be all over this! John replied, “The first thing I thought of was..’Wow this is only from three states’ and then I thought, Whoa, the appeals rate is so small!”. What this means is that 86% of the providers didn’t trust that their information was accurate and thought “why bother” rather than to appeal.

Now, John is a brilliant guy, so I take my cues from him on compliance. We banter on about Medicare, Documentation, and other such topics that we both enjoy. But, when he pointed this out to me, it really jumped off the page. Imagine that this means more than 95 percent of providers who tried to appeal, lost–and those were the ones who felt they had a strong enough case to go through the appeals process! Not surprisingly, CMS acting administrator Kerry Weems called the results a success. Of course it is a success, Weems!!!

I look at this from two directions…one of them is that the providers need more confidence in notes and systems and the other, why don’t we appeal more often!?? Back in my ACA days, it was estimated that more than 60% of claims denied on the first submission, were paid by the second appeal. Dr. John pointed out to me that it was because a different review nurse had to look the 2nd time. Now, that same review nurse can look the second time, and so the 1st appeal may go the same way. With the addition of the QIC for 2nd appeals (Qualified Independent Contractors), that appeal number will come more into line again. A different set of eyes looks at the 2nd level of appeal. But, doctors, why are you not appealing?

I think it’s for some of the following reasons: 1) No confidence in your notes and systems; 2) Don’t know how to appeal; 3) Feel like it’s not worth it or “what’s the point” since only 4.5% of the 14% that appealed were overturned. Here’s the truth! Most DC’s don’t appeal Medicare and other carriers because there is no confidence in your notes and systems. But guess what? If everyone appeals, they have to start paying more claims, don’t they!?

Don’t be a part of the problem…be a part of the solution. Here’s my recommendation: 1) Get help up front! If you need to know your notes are bulletproof, get help up front. That’s what Dr. John’s company does as well as others. 2) Get your systems locked in. That’s what many of us do to help doctors get the systems in order that include doing it right up front, and then appealing. Even Dr. John’s war cry of “Appeal to the End” will fall on some deaf ears, if you haven’t gotten the help and systems in place up front.

This RAC program will not go away. Here’s the good news: If you go through your own appeals process and your claim is paid, there is no “double jeopardy”. This means that due to the context of the program, no more review or overturning can happen on that claim. That is a sturdy reason for me to want to appeal every claim, to the end.

So, when you get that inevitable letter asking for notes, don’t brush it off. Know that it’s a warning sign. Then take your temperature…are you cold and clammy? Fearful? Or confident and defiant? If you don’t feel confident and defiant, get some help! Not only will your office benefit, but the profession as a whole! Thoughts?