Are you up the challenge? As margins decrease and requirements increase on your time and money, what can you do to meet these challenges? Do you have the best technology solutions available or are you still limping along afraid to make a change? Do you still manage your daily operations doing the same old things? It's time to stop and reconsider your options, for you do have options, but you need to spend some time to find the right opportunities for your operation. We can help; contact us for a free demonstration. |
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RAC TRAC
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Why is CMS using recovery audit contractors? Section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) required CMS to complete a demonstration project to demonstrate the use of recovery audit contractors in identifying underpayments and overpayments and recouping overpayments under the Medicare program for services for which payment is made under part A or B of title XVIII of the Social Security Act.
How long does a provider have to submit medical records when requested by a Recovery Audit Contractors (RAC)?
Providers must respond within 45 days to a RAC request for medical records. Providers may request an extension at any time prior to the 45th day by contacting the RAC.
Under what circumstances can, Recovery Audit Contractors (RAC), make a finding that an overpayment or underpayment exists without requesting medical records?
RACs may use automated review (where NO medical record is involved in the review) ONLY in situations where there is certainty that the claim contains an overpayment. Automated review must:
a) have clear policy that serves as the basis for the overpayment ("clear policy" means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment);
b) be based on a medically unbelievable service; or
c) occur when no timely response is received in response to a medical record request letter.
How will the Recovery Audit Contractors (RAC) determine which claims to review?
The RACs will use their own proprietary software and systems as well as their knowledge of Medicare rules and regulations to determine what areas to review.
How are the Recovery Audit Contractors (RAC) paid for finding and recovering overpayments?
RACs are paid on a contingency basis (i.e., they retain a portion of the monies recovered) for all accurately identified overpayments.
Bottom line this means more administrative output and decreased cash flow. It is imperative to automatically quantify and track all known payment variances.
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NEVER EVENTS |
Beginning October 1, 2008, Medicare will no longer pay at a higher weighted MS-DRG for eight diagnostic conditions, as well as any conditions CMS is proposing to add in this year's 2009 rule.
Another insurer has said it will no longer pay for hospital treatments required after clinical mistakes made by hospital staff. CIGNA Healthcare announced it will no longer reimburse hospitals for so-called ''never events' and possible avoidable hospital conditions. CIGNA is following other major payers such as Wellpoint, Inc. which recently announced that its 14 state Blue Cross and Blue Shield plans would not reimburse hospitals for serious preventable medical errors. Earlier in the year, Aetna announced the same. The original list of 'never events' consists of objects left in the body during surgery, and air embolisms. Are you tracking these denials? You may want to begin this process today.
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Medicare Transmittal Summary |
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Billing Blood & Blood Products - Revenue code 380 not acceptable, use 381/382. Effective date: October 1, 2008 See Transmittal 1495
Lab Date of Service - notable CMS policy change
1. In the case of a test/service performed on a store specimen, if a specimen was stored for less than or equal to 30 calendars days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if... See Transmittal 1515
2.In the case of a chemotherapy sensitivity test/service performed on live tissue, the DOS of the test must be the date the test/service was performed only if... See Transmittal 1515 Effective date: January 1, 2009
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| On Monday, June 16, the AMA rolled out its "Cure for Claims" campaign and its National Health Insurer Report Card(NHIRC) at the AMA House of Delegates in Chicago. The intent of the campaign is to work together with the health care industry to reduce unnecessary administrative waste in the health care claims process.
We welcome the opportunity to earn your business. Join our clients with proven clean claim results. It's what we do best. Join us and join the best.
Sincerely,
Jayne Kroner
VP, Business Development
(925)685-9300
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| NPI Rejects |
Claim rejections jumped after the NPI deadline.
According to some clearinghouse sources, Medicare and Medicaid provider claim rejections have increased to alarming levels since May 23, the Centers for Medicare & Medicaid Services' deadline for implementing its National Provider Identifier standard. Per AHA, the rejection rate of 24% for Medicare claims and 26% for Medicaid claims, up from a normal 6% and 4% respectively. |
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| Health Analytics |
| Health Analytics is going to be the most significant trend that we're going to be seeing in healthcare IT since EMR. Hospitals and other healthcare providers are starting to get a handle on their IT needs and they have a significant amount of data they're accumulating. What is not readily available is a means for collecting the data from various silos and disparate systems, collating and analyzing that data and using it to improve healthcare delivery, whether it is clinical, financial or administrative. Hospitals according to a recent Gartner study of 1500 CIO's worldwide, state that the business intelligence applications were rated the top priority over the next three years, beating out such hot topics as systems security, and updating legacy technology.
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Burning Down the House |
 Much of the process of settling injured workers' medical care remains locked in a paper world.
Most hospitals require a two set billing approach -an electronic one for most claims and a ready supply of paper for worker's compensation claims.
Effective January 1, Texas enacted a new law requiring the use of electronic billing for workers compensation cases. Texas is the first state in the country to mandate electronic workers compensation billings. The Workgroup for Electronic Data Interchange (WEDI) has formed a Workers Compensation subgroup to coordinate the use of standard billing practices in this area. Workers compensation payers have been slow to adopt electronic standards because typical cases involve so many different entities-the employer, the employee injured on the job, the insurance company, government agencies and all involved care providers. Workers Compensation communications include a First Report of Injury, subsequent Reports of Injury, proof of coverage and medical expanse payment. While some payers can electronically communicate in reimbursing for works compensation, most cannot.
Small regional payers that specialize in workers compensation and self funded plans still depend heavily on paper. One of the big problems is connectivity. Even though carriers have built systems to receive bills and providers are able to send them, the workers compensation payers have been slow to execute data sharing agreements.
We shall watch the progress in Texas for a possible fire storm of electronic workers compensation billing. |
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| Patient Access |
| CMS has changed the ABN form. The new form will be required to be used effective on September 1, 2008. Cirius has released an automated ABN solution that will eliminate Medicare write off's and ensure billing and coding compliance. These features are all driven by the most secure system and easy to use software, and you will receive the MOST responsive consultant team. If you would like to know more about the Cirius ABN software
ABN New Form |
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Client Corner |
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KLAS Testimonial |
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Client writes "Cirius is just awesome." Their software design is so perfect. They give us the standard edits for Medicare and all of the other payers, but on top of that, they have a custom edit suite where the provider can build their own custom edits. We can pretty much do anything, and it is very easy. I can put an edit in right now, test it, know it is working and run it against all of the claims. I can put an edit on any field of the claim form itself. The power of that is fantastic. January 2008.
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