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Low Volume Medicare Providers Get “Free Pass” From Auditing

Washington, D.C. – The Centers for Medicare & Medicaid Services (CMS) implemented new additional document request (ADR) limits last year that restrict Medicare recovery auditors to review no more than 0.5 percent of a provider’s total number of Medicare claims. The new ADR policy renders 99.5 percent of Medicare claims off limits from review for billing accuracy and has produced another side effect – low volume providers are now mathematically exempt from audits entirely. For example, any Medicare provider that […]

Viewpoint: Some providers receive a ‘free pass’ from auditing Medicare claims

Low-volume Medicare providers escape from having claims reviewed for accuracy under new additional documentation request limits for recovery audits, according to Kristin Walter, an opinion contributor to The Hill. Ms. Walter, spokesperson for The Council for Medicare Integrity, outlines the new policy and her viewpoint in a recent article. CMS in May 2016 revealed new ADR limits for the Medicare Fee-For-Service Recovery Audit Program. The policy calls for an annual baseline ADR limit of 0.5 percent of the provider’s paid Medicare claims from […]

Low volume Medicare providers are getting a ‘free pass’ from auditing

Back in May, 2016, the Centers for Medicare & Medicaid Services (CMS) announced new additional documentation request (ADR) limits for Medicare Recovery Audits that review claims to identify and recover improper payments. The new policy reduced the annual ADR limit so auditors can review just 0.5 percent of a provider’s total number of paid Medicare claims with an additional twist. The twist is CMS would review provider billing accuracy rates over three 45-day periods and adjust each provider’s ADR limit higher or […]

Improper Pay Rate Dips Below 10% As Home Health, IRF Rates Improve

The drop in CMS’ improper pay rate for fee-for-service Medicare was driven by a reduction in improper pay to home health agencies and inpatient rehabilitation facilities — though CMS says home health companies and IRFs, along with nursing homes, were the major contributors to the 9.5 percent improper pay rate in fiscal 2017, and the HHS Office of Inspector General said program integrity is still a top management challenge for the agency. Medicare’s improper pay rate has not been below […]

OIG: Rush University Medical Center overbilled Medicare by $10.2M

Rush University Medical Center in Chicago failed to comply with Medicare billing requirements for 57 of 120 inpatient and outpatient claims reviewed by HHS’ Office of Inspector General, according to a recent OIG report. The 57 claims that did not comply with Medicare billing requirements resulted in the hospital receiving $814,150 in combined overpayments during 2014 and 2015, according to the OIG. Extrapolating from the sample results, the OIG estimated Rush University Medical Center received approximately $10.2 million in overpayments from […]

No, RAC audits do not impact patient care

Many myths are tough to dispel because they are so often repeated. No, cold weather does not give you the cold or flu. A shark cannot smell a single drop of blood from miles away. Chewing gum does not stay in your stomach for seven years. And, be careful because lightning can, in fact, strike the same place twice. Despite being thoroughly debunked; some still believe myths like these are true. The same goes for myths about Medicare Recovery Audit […]

Appeals court overturns ruling requiring HHS to clear Medicare appeals backlog by 2021

The U.S. Appeals Court for the District of Columbia on Friday overturned an order requiring HHS to clear its backlog of Medicare reimbursement appeals by the end of 2020. On Dec. 5, 2016, U.S. District Judge James Boasberg granted a motion for summary judgment filed by the American Hospital Association in AHA v. Burwell — a lawsuit that centers on the Recovery Audit Contractor Program. He ordered HHS to incrementally reduce the backlog of 657,955 appeals pending before the agency’s Office of Medicare Hearings and Appeals over the […]

McKnights

When does a review of 0.5% make sense?

Would you feel safe flying if airlines only inspected 0.5% of their fleet of planes? What about if smoke detectors for your home were rolling off the assembly line with only 0.5% being tested to ensure that they worked to sense a fire emergency? That’s what we’re facing with payment accuracy in Medicare these days. The Centers for Medicare & Medicaid Services have drastically scaled back review of the claims providers submit to the Medicare Fee for Service program for […]

CMS Official Sidesteps Offer Of Tools To Combat Medicare Improper Pay

House Ways & Means Republicans asked CMS acting program integrity director Jonathan Morse what additional tools the agency might need to help bring down improper payment rates in Medicare — 11 percent for Medicare fee-for-service and about 10 percent for Medicare Advantage in fiscal 2016, according to the government’s payment accuracy website — but Morse did not ask for any additional authority, even though a representative from the Government Accountability Office suggested lawmakers could give CMS the authority to let […]

Medicare Trustees: Part A Program Insolvent by 2029

   Increased Focus on Reducing Improper Payments Can Extend the Life of the Medicare Program Washington, D.C. – A new Medicare Trustees report today predicts that the Medicare inpatient Trust Fund will only be fully funded until 2029. After that, Medicare Part A will only have enough to fund 88 percent of what’s covered today. The report goes on to warn lawmakers and the executive branch that they must “work closely and with a sense of urgency” to ensure the […]