Transcript RAC Update
RAC Update GAHA: 2014 Health Care Law Update May 16, 2014 Tracy M. Field, M.S., J.D. Womble Carlyle Sandridge & Rice, LLP 271 17th Street, NW – Suite 2400, Atlanta, GA 30363 (404) 962-7539 MEDICARE AUDITS Now What? Perspective: • By challenging denials, CMS changed the rules! • Compliance challenge: How assess accuracy? • Business reasons for rebilling Part B • 2 year backlog – and growing! ALJ BACKLOG OMHA February 2014 Forum Office of Medicare Hearings and Appeals (OMHA) Forum: February 12, 2014 • Backlog of 500,000 cases – and counting! • Moratorium on docketing new appeals until workload addressed per ALJ o Hearings being scheduled ALJ BACKLOG OMHA February 2014 Forum • Backlog o Budget increase: 18+% (after sequester) o Statistical sampling? ‒ OMHA statistician ‒ Appropriate for fact-specific cases o Mediation/Alternative Dispute Resolution o New regulations ALJ BACKLOG OMHA February 2014 Forum • No longer need to submit medical records? • Group cases – but individually file! • Electronic filing? o Send files via tracking methods, and don’t expect an acknowledgment! o Miami pilot o 2 year development from award ALJ BACKLOG OMHA February 2014 Forum • Backlog o Increase in Escalation to DAB-MAC ‒ NO Hearing at DAB-MAC ‒ Access to federal court sooner – but… o OMHA stated testimony makes difference - yet o OMHA suggested may not want to request hearing? ALJ BACKLOG OMHA February 2014 Forum • Legal Considerations o Medicare Modernization Act (MMA) and BIPA deadlines not being met o For medical necessity cases, what standard of review applies? o Confusion on effective dates for local coverage determinations (LCDs) o Jimmo Case: Important for rehab, other uses? ALJ BACKLOG OMHA February 2014 Forum • Compliance Considerations o Part A/B Claims: 97% of appeals o Redetermination reversal rate to fully favorable: ‒ 30% per OMHA ALJ BACKLOG OMHA February 2014 Forum For OMHA Outcomes of Cases Decided at ALJ • 37% Fully Favorable – 4% Partially Favorable • 30% Unfavorable • 1% Remand • 27% Dismissed Impact on Compliance activities…. RAC REPORT (March) 2014 For FYE 2012: o Increasing RAC Activity » Medicaid RACs » Data warehouse » Validation audits, education » “Maximize transparency” » Hearing Participation RAC REPORT (March) 2014 For FYE 2012: o Collected $2.3 Billion in overpayments… o New initiatives to prevent provider appeals? » The 2 Midnight Rule » Subregulatory Guidance? MAC REVIEWS RAC Denial Redetermination (MAC) Qualified Independent Contractor (QIC) Administrative Law Judge (ALJ) Medicare Appeals Council (MAC)/Departmental Appeals Board (DAB) Federal Court 17 INITIAL REVIEWS Probe Audits MAC Audits: January 2014 • MAC prepayment reviews: “probe and educate” Recovery Audits: • Delayed until November 2014 – but the probe audits continue…. INITIAL REVIEWS Probe Audits Presumptions that Hospital Stays Less than 2 Midnights are Not Medically Necessary • Presumption does not mean wrong!! • Legal challenges to denials • Strategy to avoid audits o Some opted for no one-day stays o Rebill under Part B? MEDICARE APPEALS Other Considerations IPPS Proposed Rule: Payment for Short Stay Admissions: • Payment under OPPS or IPPS? AHA Litigation: • Challenges the 2 Midnight Rule; Part A/B Rebilling time limitations and physician certification of orders as payment condition REFERENCES www.hhs.gov/omha • Per OMHA: Updates after 15th of each month on adjudication timelines, processes • OMHA Adjudication Manual Pending QUESTIONS? Tracy M. Field, M.S., J.D. [email protected] (404) 962-7539 Womble Carlyle Sandridge & Rice, LLP 271 17th Street, N.W. Suite 2400 Atlanta, Georgia 30363