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Revenue Cycle Institute’s RAC Readiness Summit faculty announced
HCPro’s Revenue Cycle Institute has announced the faculty for its seminar: Recovery Audit Contractor Defense: A RAC Readiness Summit to be held March 19-20, 2009 in Phoenix, AZ.
Faculty include the following:
- Patricia Blaisdell is vice president for postacute care services with the
California Hospital Association. She provides membership support and advocacy for hospital-based medical rehabilitation and skilled nursing facilities, including policy analysis and interpretation, communication with regulatory bodies and third-party payers, and planning and implementation of educational programs. - Yvonne Focke, RN, BSN, MBA, is a national revenue cycle consultant
who has conducted training and education sessions for hospital clients as part of HCPro, Inc.’s Revenue Cycle Institute. She is a former regional director of revenue cycle management at Mercy Health Partners in Southwest Ohio. Prior to that position, she was director of Access and Care Management for TriHealth Inc. in Cincinnati. She has also served as a presenter on the national stage for professional organizations including HFMA and NAHAM. - Adriana van der Graaf, MBA, RHIA, CHP, CCS, is currently Vice
President, Revenue Cycle for Cymetrix. She is based at Saint John’s Health Center in Santa Monica, CA. She is responsible for the management of the entire hospital revenue cycle, including Patient Access, Health Information and Patient Financial Services. She has more than 20 years of experience in HIM in roles ranging from a diagnostic coding instructor to many years as an HIM director, and has been responsible for overseeing the medical records functions and policies of numerous separate clinics with staff members working in multiple areas. - Stacey Levitt, RN, MSN, CPC, is director of patient care management at Lenox Hill Hospital in New York City. She has a solid clinical nursing background in both critical care and public health. Her ongoing administrative experience includes over twenty years in healthcare management settings in New York and Pennsylvania. Her areas of expertise include utilization and denial management, reimbursement analysis, performance improvement, professional staff development, and project management. She is known for her in-depth knowledge of Medicare egulations and her passion for effecting increased efficiency, productivity, mastery of insurance coding rules, and realization of appropriate reimbursement. She is an expert in data management and analysis relating to hospital and physician reimbursement.
- Tanja Twist, MBA/HCM, is director of patient financial services at
Methodist Hospital of Southern California in Arcadia. In her current position she is responsible for oversight of the admitting and business offices at Methodist Hospital, a 460-bed, not-for-profit hospital serving the central San Gabriel Valley, CA. She has been in healthcare management for more than 20 years and is the current national finance chairperson for the American Association of Healthcare Administrative Management (AAHAM), the government relations chairperson for the
Southern California chapter of AAHAM, and a current member of the HFMA. She also sits on the advisory board of HCPro, Inc.’s The RAC Report. - Joe Zebrowitz, MD, is executive vice president and senior medical director of Executive Health Resources (EHR) in Newtown Square, PA. In this role, he developed EHR’s suite of clinical revenue cycle management services—endorsed by the American Hospital Association as “Best in Class.” EHR’s programs focus on clinical denial reduction, length-of-stay management, governmental claims, compliance, and physician education through daily physician-to-physician interaction. Zebrowitz works as a physician advisor and medical director at EHR client hospitals, leading clinical denial management and length-of-stay programs, quality initiatives, documentation and compliance programs, and independent peer review processes.
Click here for more information about the Recovery Audit Contractor Defense: A RAC Readiness Summit.
CMS delays RAC permanent program
CMS yesterday announced it has delayed the Medicare Recovery Audit Contractor (RAC) permanent program and put a moratorium on all RAC-relayed informational sessions across the country. CMS has yet to release further details but told the American Hospital Association the action was necessary due to “a RAC protest and a stay of performance.”
However, the California Hospital Association (CHA), in a memorandum obtained by HCPro., Inc, says that PRG Schultz (PRG), a contractor that submitted a bid for work in the permanent program but wasn’t selected as one of the four permanent contractors, was considering a challenge to the contract award process.
Despite the delay in the process, Joseph Zebrowitz, MD, executive vice president of Executive Health Resources in Newtown Square, PA, warns facilities not to change anything in terms of preparing for a RAC visit. The permanent program will not change, he says.
“Basically, this is infighting amongst CMS potential contractors who are upset that they were not awarded the RAC contract,” Zebrowitz says. “I think it is important that this delay is not because of any question of whether the RACs are fair, or good, or legal. The RAC program is unchanged, and there is nothing out there to say that anything is going to be different. [CMS] just can not start when the contractors are in doubt. Once they resolve these complaints, they will start up.”
Zebrowitz guessed the delay would take 30 to 60 days.
PRG Schultz, which had the lowest percentage of appeals overturned in the demonstration project (2.1%), boasted last month of netting one of the highest technical scores in the demonstration project. It said CMS denied its contract because of its high contigency fee bid.
Monday, CMS ordered a blanket shutdown of all RAC activity, including its informative sessions (one in New Hampshire was stopped mid-conference yesterday, CHA says). The Healthcare Association of New York (HANYS) said a RAC videoconference briefing scheduled for Wednesday through the state was canceled.
CMS had announced the new RACs for its permanent nationwide program Monday, October 6. The four contractors and their selected regions are:
- Diversified Collection Services, Inc. of Livermore, CA: Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.
- CGI Technologies and Solutions, Inc. of Fairfax, VA: Region B, initially working in Michigan, Indiana and Minnesota.
- Connolly Consulting Associates, Inc. of Wilton, CT: Region C, initially working in South Carolina, Florida, Colorado and New Mexico.
- HealthDataInsights (HDI), Inc. of Las Vegas, NV: Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.
CMS said it chose the contractors and their regions based on three values:
- A “best value determination” that includes a strong technical approach and “exceptional” customer service
- Conflict of interest reviews
- Lowest contingency fee
CMS also announced last month how much money RACs will make from provider overpayments. The RACs get paid “contingency fees” based on the amount of the improper payments they correct for both overpayments and underpayments.
“Each RAC’s contingency fee is established during contract negotiations with CMS and, as such, the contingency fee varies for each RAC,” CMS said.
The contingency fees breakdown as follows:
Region A: 12.45%
Region B: 12.50%
Region C: 9%
Region D: 9.49%
News: Six Nevada doctors pay to settle Medicare fraud claims
Six Las Vegas area doctors agreed to collectively pay over $600,000 for their role in a Medicare fraud scheme, according to a report issued by KTNV, a Las Vegas news station.
The six doctors, Robert Shreck, MD, Tony Q.F. Chin, MD, Craig M. Jorgensen, MD, Wen Liang, MD, Mohammed Najmi, MD, and Edmund Pasimio, MD, allegedly referred patients to a nurse practitioner, Greg Martin, for medically unnecessary procedures.
Martin allegedly billed Medicare for the procedures and, upon receiving payment, split the amount with the referring physician.
To read the full KTNV story, click here
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
West Jefferson Medical Center, a New Orleans area hospital, agreed to pay $3.3 million to resolve allegations of Medicare fraud, according to a Department of Justice (DOJ) press release.
The charges alleged West Jefferson Medical Center lied about its ability to provide critical care services at its pediatric intensive care unit. The alleged lie caused the hospital to receive overpayments from Medicare between March 1998 and October 2003.
Leslie Klemm, a former nurse at the hospital, filed the qui tam suit and will receive $627,000 as her share of the state and federal recovery.
To read the full DOJ press release, click here
Hospitals absorb costs of treating uninsured immigrants
Hospitals absorb costs of treating uninsured immigrants
Hospitals in New York, Connecticut, and New Jersey are increasingly finding themselves providing uncompensated care to poor, uninsured, and sometimes illegal, immigrants.
These hospitals face a dilemma because they feel it is their ethical obligation to provide care to those who show up at their door, according to The New York Times, but some hospitals report losing up to $10 million a year caring for these types of patients.
Medicaid covers illegal immigrants in emergency situations, but other conditions, which may be debilitating but are not emergencies, are not covered.
Hospital officials say that providing care at the time the patient presents to the hospital, even if it’s not an emergency situation, can save the hospital money by dealing with the health issue before it becomes urgent. In addition, community education about available healthcare resources can prevent patients from coming to the hospital if they are aware of other options.
Sources: HealthLeaders Media, The New York Times
Eight indicted in South Florida AIDS/HIV infusion scheme
Federal and state Medicare Strike Force agents indicted eight individuals – Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco – in the Miami area for alleged involvement in a scheme to defraud Medicare.
According to the Department of Justice press release, the scheme involved two Miami medical clinics—Medcore Group LLC and M&P Group of South Florida Inc. Tony Marrero, Pascual, and Belkis Marrero controlled day-to-day operations for those clinics.
According to the indictment, medical assistants Borrego, Pacheco, and Milanes administered unnecessary treatments and paid cash to patients. Rothman and Russell allegedly performed cursory examinations and signed the appropriate documentation to make it appear the infusions were medically necessary.
The indictment also alleges the defendants laundered a portion of the proceeds to pay the patients for their participation in the scheme.
To read the DOJ press release click here
News: Doctors not prepared to counsel on patient finance
A new survey reveals that most doctors are inadequately prepared to counsel patients on the newer, consumer-directed health plans, Forbes reports.
The plans, which are designed to put more responsibility for healthcare decisions on the individual patient, often include health savings accounts and have high deductibles.
But 43% of doctors said they have heard very little about these consumer-directed plans, and less than 48% believe they are prepared to address financial matters with their patients.
“I think as these plans roll out, it’s really important to educate doctors about (them) and about some of the differences between these plans and more traditional models of insurance,” said study co-author Dr. Craig Pollack, as reported in Forbes.
To read the full story, click here.
News: McKesson charged with Medicare fraud scheme
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
CMS announces contractors for permanent RAC program
News: McKesson charged with Medicare fraud scheme
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
CMS announces contractors for permanent RAC program
CMS announced the new Medicare Recovery Audit Contractors (RACs) for its permanent nationwide program Monday, October 6. The four contractors and their selected regions are:
- Diversified Collection Services, Inc. of Livermore, CA: Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.
- CGI Technologies and Solutions, Inc. of Fairfax, VA: Region B, initially working in Michigan, Indiana and Minnesota.
- Connolly Consulting Associates, Inc. of Wilton, CT: Region C, initially working in South Carolina, Florida, Colorado and New Mexico.
- HealthDataInsights (HDI), Inc. of Las Vegas, NV: Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.
CMS said it chose the contractors and their regions based on three values:
- A “best value determination” that includes a strong technical approach and “exceptional” customer service
- Conflict of interest reviews
- Lowest contingency fee
Connolly and HDI worked on the initial RAC demonstration project that spanned over six states, collected more than $900 million in overpayments, and returned nearly $38 million in underpayments to healthcare providers, according to a CMS press release.
PRG denied contract
CMS said it chose not to select PRG-Schultz (PRG), which had the lowest percentage of appeals overturned in the demonstration project (2.1%). CMS had awarded PRG the California contract. In a press release, PRG said it received one of the highest technical scores but was denied a permanent contract because of its high contingency fee bid.
Tanja Twist, director of patient financial services at Methodist Hospital in Arcadia, CA, said she is “very glad to see that PRG wasn’t selected as one of the ‘Permanent 4’ given their track record here in California.” The California Hospital Association released a memorandum in July citing several concerns over PRG’s work on inpatient rehabilitation facilities (IRFs).
Lowdown on returnees
CMS reports through June 30, 2008 that HDI led all contractors in the demonstration project with 239,205 overpayment determinations. Providers have been the most successful with appeals against HDI (11.5%). Connolly was second with 110,635 and had 4.2% overturned on appeals.
CMS did not release information on the two new RACs – Diversified Collection Services (DCS), Inc. and CGI Technologies and Solutions, Inc. However, the federal government is familiar with DCS. In fiscal year 2007, the government awarded them $36,590,770 in contracts, according to www.fedspending.org, the Freedom of Information Web site on government spending.
Getting prepared
Facilities need to plan immediately for the RACs’ arrival, said William Malm, ND, RN, partner at Health Revenue Integrity Service LLP. Connolly, which had the New York contract in the demonstration project, and HDI, which had the Florida contract in the demonstration program, will not be in those states for the permanent program. So those providers in the demonstration states should be prepared for a different contractor in the permanent program.
The new RACs will begin to educate and inform providers later this month and in November about the program, CMS said. Kimberly Anderwood Hoy, JD, CPC, director of Medicare and Compliance for HCPro, Inc., said one of the new elements of the permanent program is the RAC Validation Contractor, which will approve issues for review by the new RACs. In addition, the contractors will create a Web site to post new topics the RACs are investigating.
NYU Medical Center worked with Connolly during the demonstration project. Robert Tipton, NYU’s RAC liaison and its director of inpatient revenue cycle operations, said Connolly established a solid working relationship with the hospital during the process. Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill (NY) Hospital, agreed.
“This might sound contradictory, as the RAC’s primary function is to identify overpayments and potentially recoupment money from the hospitals,” Tipton said. “But the reality is that the RAC is here to stay, and creating a working, professional relationship benefits both sides at the end of the day.”
MORE RAC TIPS: What patient access managers should watch
Editor’s note: These tips are provided by Tanja M. Twist, director of patient financial services at Methodist Hospital in Arcadia, CA. Twist is the finance chair for the American Association of Healthcare Administrative Management (AAHAM) who has fought Congress on Capitol Hill for better transparency and answers to concerns with RACs on behalf of hospitals.
1. Review your ED admissions. Twist cautions that many admissions from the ER are made because the facility needs to free up ED beds, which can lead to medical necessity problems with the RAC. “Emergency rooms are busy all across the country,” Twist says. “A key component is to make sure you meet the medical necessity criteria for the ER admissions too. The nature of the emergency department beast is things get rushed, but you have to ensure there are protocols in place to watch the ER admissions, too.”
If you do not have a 24/7 ED case coordinator position that monitors admissions, ensure someone like your case manager or you, the patient access manager, comes in first thing in the morning to clean up the admissions, she says.
2. Review your one-day stays. “This is another piece the RACs are focusing on,” Twist says. “Should those patients be observations? I’ve seen admitting orders just say ‘admit.’ You have to make sure that physician orders have an ‘admit to acute or admit to observation’ designation. There could be some type of check box for the physician to clearly indicate his selection. From here, the concern is whether or not the acute admission meets criteria.”
