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American Academy of Family Physicians
Tuesday Jul 22, 2014

Improve the chances of your Medicare claims for obesity counseling

The most recent issue of the Medicare Quarterly Provider Compliance Newsletter said that documentation for obesity counseling has led to numerous instances of overpayment and other errors. Here’s what you need to know to ensure your documentation passes muster in an audit.

First, Medicare covers and pays for behavioral counseling for beneficiaries with obesity, measured as a body mass index (BMI) of 30 kg/m2 or greater. Specifically, obese Medicare beneficiaries are eligible for:

•    One face-to-face visit every week for the first month;
•    One face-to-face visit every other week for months 2-6; and
•    One face-to-face visit every month for months 7-12, if the beneficiary achieves the required weight loss.

Per Medicare, beneficiaries must be competent and alert at the time that they receive counseling, and the counseling must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Additionally, at the six-month visit, the beneficiary should receive a reassessment of obesity and a determination of the amount of weight loss. To be eligible for additional face-to-face visits occurring once a month for during months 7-12, beneficiaries must achieve documented weight loss of at least three kilograms (6.6 lbs.) during the first six months of intensive therapy.

Obesity counseling is reported with Healthcare Common Procedure Coding System (HCPCS) code G0447, “Face-to-face behavioral counseling for obesity, 15 minutes.” Medicare reviewers conducted a special study of HCPCS code G0447. Upon review, they determined that insufficient documentation caused approximately 92 percent of the improper payments. Examples of “insufficient documentation” included:

•    No physician’s signature on the encounter note
•    No documentation of the patient’s clinical condition
•    No documentation that the beneficiary has a BMI greater than or equal to 30kg/m2
•    No documentation that after six months the beneficiary lost 6.6 pounds or 3kg
•    No documentation that obesity counseling and dietary assessment actually occurred

So, to help improve the chances that your claims for obesity counseling will stand up to Medicare scrutiny, you need to document the patient’s clinical condition and qualifying BMI. You also need to document how much weight the patient has lost at the six-month mark and the counseling and dietary assessment that occurred at each visit. Finally, don’t forget to sign the encounter note when you’re done.

Medicare covers intensive behavioral therapy for obesity per National Coverage Determination 210.12. You can learn more about this benefit and the associated rules by reading section 200 of chapter 18 in the Medicare Claims Processing Manual as well as the Medicare Learning Network Matters article on obesity counseling.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday Jul 16, 2014

CMS looks to add new code to track care provided off hospital grounds

If you're in a family medicine practice owned by a hospital or other health system, the recently proposed 2015 Medicare physician fee schedule offers some new reporting requirements.

The Centers for Medicare & Medicaid Services (CMS) wants to require hospitals and physicians to report a coding modifier for those services furnished in an off-campus, provider-based department.  

The modifier would be reported on both the claim form for physicians’ services and on hospital outpatient claims. CMS defines a hospital campus to be the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the CMS regional office. The new rule would apply to everything outside of that.

CMS said the information collected will help it improve its practice expense data and methodology under the physician fee schedule and more appropriately account for the different resource costs among traditional office, facility, and off-campus, provider-based settings.

The AAFP has prepared a summary of these and other changes proposed by CMS. You can access the full proposed rule  through the CMS web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday Jul 11, 2014

Medicare proposes paying for chronic care management

The Centers for Medicare & Medicaid Services (CMS) wants to begin reimbursing physicians for some of the unpaid care management services they provide patients with several chronic conditions.

Contained in CMS's proposed 2015 Medicare physician fee schedule, the provision would pay approximately $42 for the chronic care management (CCM) code no more than once per month per qualified patient. The payment is intended to compensate physician practices for non-face-to-face CCM services for Medicare beneficiaries who have two or more significant chronic conditions.

Under the proposal, CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. Other requirements to bill Medicare for CCM services include:

• Access to care management services 24 hours a day, seven days a week, which means providing beneficiaries with a way to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.

• Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.

• Care management for chronic conditions, including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.

• Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

• Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after a beneficiary visit to an emergency department; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.

CMS proposes that practices use an electronic health record (EHR) or other health information technology or information exchange platform to furnish the CCM services. It also says that technology solution should include an electronic care plan that is accessible to all providers within the practice, regardless of the hour of day, as well as being accessible to care team members outside of the practice. Physicians and other qualified health care professionals furnishing CCM services beginning in 2015 would be required to use an EHR certified to at least 2014 Edition certification criteria.

The AAFP has prepared a summary of this and other changes proposed by CMS.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 24, 2014

Medicare to expand its use of prior authorization

The Centers for Medicare & Medicaid Services (CMS) is looking to expand its requirements that it provide prior authorization before Medicare beneficiaries can receive certain medical devices or supplies.

In a May release, CMS said it plans to more than double the number of states where it has prior approval power over power mobility devices, launch new prior authorization trials for two types of non-emergency services, and get public comment on establishing prior authorization rules for a number of other devices and supplies it says are frequently prescribed to patients who don't need them.

Since 2012, CMS has operated the Medicare Prior Authorization of Power Mobility Device Demonstration in seven states:  California, Florida, Illinois, Michigan, New York, North Carolina, and Texas. CMS believes the demonstration project has been sufficiently successful and plans to extend it to an additional 12 states. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, and Washington.

CMS will also launch two new payment model demonstrations to test prior authorization for certain non-emergent services under Medicare. These services include hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transport. CMS hopes that information from these models, each being held in three states, will let officials fine-tune future policy decisions on the use of prior authorization in Medicare.

Finally, CMS has proposed to establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that it believes are frequently prescribed but unnecessary. Through a proposed rule, CMS is soliciting public comments on the process and criteria for selecting durable medical items subject to the new rules. The deadline to submit comments is July 28, 2014.

You can find additional information on CMS's prior authorizations initiatives on the CMS web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 17, 2014

Potential pitfall in Medicare billing: office visits billed for hospital inpatients

This week, we conclude our series (see previous posts here, here, and here) on how to avoid common Medicare billing errors by focusing on billing the wrong kind of evaluation and management (E/M) code for patient visits provided in a hospital inpatient setting.

If you are rendering an E/M service to a patient in an inpatient hospital setting, then you should typically report that service with a CPT code from one of the following families:

•    99221-99223 – Initial hospital care
•    99231-99233 – Subsequent hospital care
•    99238-99239 – Hospital discharge services

Unfortunately, Medicare contractors are finding that physicians sometimes use a CPT code from the 99201-99215 family (Office or other outpatient services) for encounters with hospital inpatients. The example given is an 80-year-old female admitted to a hospital for an inpatient level of care on Oct. 17 and discharged on Oct. 20. A physician billed CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient) for the date of service of Oct. 18. Because Oct. 18 was during the inpatient hospital stay and the patient was not on a leave-of-absence from the hospital on that date, the contractor deemed the service an overpayment.

So, if you are billing E/M services for a patient in an inpatient hospital setting, then you need to use hospital visit codes to report those services and avoid office/outpatient visit codes for dates of service corresponding to the patient’s hospital stay.

For additional information, check out Medicare’s Evaluation and Management Services Guide and sections 30.6.9.1, 30.6.9.2, and 30.6.10 of chapter 12 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 10, 2014

Potential pitfall in Medicare billing: modifer misuse

Over the past two weeks, we have discussed how to avoid common Medicare billing errors recently identified by the Centers for Medicare & Medicaid Services (CMS). This week, we’ll focus on the pitfalls associated with a commonly used billing modifier.

There are times when family physicians do multiple, separate procedures on the same patient at the same session or on the same day, for which separate payment may be allowed. Medicare rules state that the second and any subsequent procedures are subject to reduced payment in this situation. Physicians are to identify such services by appending modifier 51 (multiple procedures) to the codes for the second and subsequent procedures. Medicare, in turn, reduces the payment allowance by 50 percent for codes with modifier 51 attached.

Unfortunately, the CMS has identified situations in which physicians are appending modifier 51 to a procedure code even when that procedure is the only one provided to the patient on that date. In those situations, the physicians are generating inappropriate underpayments of up to 50 percent and shooting themselves in the foot financially. The easy answer is to NOT append modifier 51 to any code in the surgery section of Current Procedural Terminology (codes 10021 to 69990) if that is the only code from that section provided to the patient on that date.

For further resources, CMS advises that you read section 40.6 of chapter 12 and section 30 of chapter 23 of the Medicare Claims Processing Manual. Next week, we’ll wrap up this series of posts by looking at the pitfalls associated with billing office visits for hospital inpatients.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 03, 2014

Potential pitfall in Medicare billing: preventive services

Last week, we began looking at some of the common Medicare billing errors identified by the Centers for Medicare & Medicaid Services (CMS) in its most recent Medicare Quarterly Provider Compliance Newsletter. This week, we’ll focus on another of those pitfalls, this one associated with Medicare-covered preventive services.

In recent years, the CMS has expanded Medicare coverage of preventive services to include many recommended with a grade of A or B by the United States Preventive Services Task Force. These services (and their corresponding Medicare billing codes) include:

•    Annual alcohol misuse screening, 15 minutes (G0442)
•    Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443)
•    Annual depression screening, 15 minutes (G0444)
•    Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes (G0446)

Unfortunately, Medicare contractors have determined that insufficient documentation is causing many improper payments for these services. “Insufficient documentation” in this context means that something was missing from the medical records, such as:

•    No record of the amount of time spent providing a timed service
•    No record of the billed service itself
•    No physician’s signature on the medical record

To avoid these potential problems, CMS advises physicians to:

•    Record start and stop times, or the total time spent, when providing a timed service
•    Sign entries in medical records at the time of service
•    Learn about the non-covered indications and frequency limits for preventive services under Medicare

To the last point, you should know that:

•    Screening for depression is not covered when performed more than once in a 12-month period
•    Alcohol screening is not covered when performed more than once in a 12-month period
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than once a day
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than four times in a 12-month period.

You can find additional information and links to other relevant resources in the newsletter. Next week, we’ll look at the pitfalls associated with misuse of a common coding modifier.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday May 30, 2014

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Four times a year, the Centers for Medicare & Medicaid Services (CMS) publishes its Medicare Quarterly Provider Compliance Newsletter, which seeks to help physicians avoid common Medicare billing errors. The latest issue highlights at least four errors that may be relevant to family physicians. This week, we’ll cover one related to psychotherapy provided in conjunction with an evaluation and management (E/M) service.

Family physicians are often the first point of contact for patients with mental health issues and sometimes provide psychotherapy to such patients in addition to an E/M service at the same encounter. Since January 2013, these services provided by the same provider on the same day are separately reportable and payable as long as they are significant, separately identifiable, and billed using the correct codes. In this situation, designated add-on codes are used to report psychotherapeutic services performed in addition to E/M codes.

Those CPT codes are:

•    +90833: Psychotherapy, 30 minutes with patient and/ or family member when performed with an E/M service
•    +90836: Psychotherapy, 45 minutes with patient and/ or family member when performed with an E/M service
•    +90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service

CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

•    90833: 16 to 37 minutes
•    90836: 38 to 52 minutes
•    90838: 53 minutes or longer

Psychotherapy sessions lasting less than 16 minutes are not separately reportable.

Documentation is crucial here. Time spent for the E/M service must be recorded separately from the time spent providing psychotherapy, and time spent providing psychotherapy cannot be used to meet criteria for the E/M service. Physicians can't enter one time period that includes both the E/M service and the psychotherapy.

CMS identified this blending of time periods as a common billing error in its quarterly newsletter. For example, a physician billed for a level 3 E/M service (99213) and 45 minutes of psychotherapy (90836). However, an authenticated printed visit note from the physician's electronic health record indicated total face-to-face time with the patient of 45 minutes and did not separately indicate the time spent providing psychotherapy services. The Medicare contractor, after an unsuccessful request for additional information, counted the claim as an overpayment due to insufficient documentation and recouped the payment from the physician.

Next week:  pitfalls associated with preventive services

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday May 22, 2014

One-stop shopping Medicare quality reporting programs

One of the downsides to participating in multiple Medicare quality reporting programs, such as the Physician Quality Reporting System (PQRS) or Meaningful Use, is that you often have had to report the same data separately for each.

The Centers for Medicare & Medicaid Services (CMS) has heard your woes, however, and created a new interactive tool that will help you submit your quality data one time only and earn credit for multiple programs.

The “Reporting Once for 2014 Medicare Quality Reporting Programs” tool provides guidance based on how you plan to participate in PQRS in 2014:

•    As an individual eligible professional
•    As part of a group practice
•    As part of a Medicare Shared Savings Program Accountable Care Organization (ACO)
•    As part of a Pioneer ACO

Using the interactive tool, you will learn whether you will be eligible for PQRS incentives in 2014, will avoid PQRS Medicare penalties in 2016, and can satisfy the clinical quality measure component of the Medicare Electronic Health Record (EHR) Incentive Program. If you are part of a group practice with 10 or more eligible professionals, the tool will also help you assess the impact of your participation in PQRS on the Value-Based Payment Modifier.

You can use these streamlining options only if you have participated in the Medicare EHR Incentive Program for more than a year, and you are still required to report your core and menu objectives through the CMS Registration & Attestation System.

To use the interactive tool, simply click on the green “Start” button on page two of the tool. You can also use the “How to Report Once for 2014 Medicare Quality Reporting Programs” fact sheet  for an overview of the quality programs and reporting once in 2014.

For step-by step instructions for 2014 PQRS participation, view the PQRS How to Get Started web page on the CMS web site. If you have additional questions, contact the QualityNet Help Desk at 866-288-8912 or via qnetsupport@hcqis.org. The Help Desk is available Monday through Friday from 7:00 a.m. to 7:00 p.m. (Central Time).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday May 01, 2014

Acting now to avoid a PQRS payment adjustment in 2016

While 2016 is more than a year and a half away, what you do in 2014 will determine whether or not you are subject to a Medicare payment adjustment under the Physician Quality Reporting System (PQRS) in 2016. In essence, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (Jan. 1-Dec. 31, 2014):

  • If participating as an individual eligible professional: Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive. Or, participate in PQRS via qualified clinical data registry, qualified registry, or claims reporting and report at least three measures covering one National Quality Strategy (NQS) domain for at least 50 percent of your Medicare Part B fee-for-service (FFS) patients.

  • If participating as a group practice: Meet the Group Practice Reporting Option requirements for satisfactory reporting. Or, participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.

More information is available via the PQRS web page on the Centers for Medicare & Medicaid Services' website. You may especially want to look at their new fact sheet for guidance on how to avoid the 2016 PQRS payment adjustment. You can also contact the QualityNet Help Desk 7 a.m.-7 p.m. (Central Time), Monday through Friday, by calling 866-288-8912 (TTY: 877-715-6222) or by sending an email to qnetsupport@hcqis.org.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Apr 22, 2014

Dealing with the opportunities and threats of the new Medicare data release

This month's release by the Centers for Medicare & Medicaid Services (CMS) of a public use file on Medicare physician utilization and payment data creates both opportunities and threats for family physicians. We're going to consider both.

On the plus side, the release of the Medicare data provides a great opportunity for the family medicine community to highlight the complexity of care that family physicians provide. Also, the data show wide variation in total payments made among various medical specialties, which reinforces the point that primary care physicians are underpaid relative to other specialists and sub-specialists. When that data set is further studied, it may make the case that family physicians, who provide comprehensive and time-intensive health care to their patients, are undervalued from a payer perspective.

On the other hand, the Medicare data set has lots of limitations. For example, physicians weren't given an opportunity to review the data for potential errors; the data don't measure the quality of care provided; there's no allowance for residents or nurse practitioners filing claims under a physician's national provider identifier, meaning the payment numbers could be inflated; Medicare payments may not always cover the costs of treatment, which makes the numbers an inaccurate portrayal of physician compensation; the data are not risk-adjusted, don't account for patient mix or include care for private insurance patients or Medicaid beneficiaries; the numbers don't reflect the often higher reimbursements provided in facility settings versus a physician's office; and they don't consider changes in Medicare's coding and billing rules that may different over time and across regions of the country.

Those weaknesses presents several threats:

•    Insurers, hospitals, and accountable care organizations could use the data to assess physicians’ charges and potentially drop those individuals deemed to be high-cost physicians.
•    Public and private insurers might use the data as a reason to impose additional prior authorization requests for expensive Part B drugs.
•    The data set has the potential to paint a negative picture of some physicians with patients, and it also has the potential to further enhance the perception that physicians are overpaid relative to the average U.S. worker.

Finally, the data may generate some difficult questions from patients or local media. Here are some points to emphasize if you find yourself in such a conversation:

•    Greater transparency in the health care system is a laudable goal, and there is potential value in the release of Medicare payment data for ensuring the quality of care for patients and efficient use of resources in the delivery of health care services.
•    Release of this data shines a light on the need to reform physician payment away from fee-for-service and toward payment for quality of care.
•    Data should include context and background on physician payments so that policy makers, patients, and the public understand the overall quality of care their physicians provide.
•    The data release still needs safeguards to ensure that neither false nor misleading conclusions are derived from this information, which has its limitations.
•    Medicare payment information by itself does not describe a physician’s practice.
•    Hopefully, researchers will use this data to understand and improve how health care dollars are spent, so that we can also improve the health of patients, families, and communities.

Whether the potential opportunities outweigh the potential threats remains to be seen. However, knowing what they are provides a starting point for trying to maximize the former while minimizing the latter. For more information on this subject, check out the AAFP's "Physician Payment Transparency" web page and read the frequently asked questions on the CMS website.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday Apr 16, 2014

Medicare releases physician claims data for public consumption

Last week, the Centers for Medicare & Medicaid Services (CMS) released on its website a data set detailing payments made in 2012 to more than 880,000 physicians from the Medicare Part B Fee-for-Service program.

The release of the physician claims data came in response to a legal challenge from the Wall Street Journal, which successfully argued for a federal judge to lift a 1979 injunction preventing CMS from publishing the information. CMS initially planned to evaluate requests for physician payment information on a case-by-case basis. But after receiving numerous requests for the Medicare data, CMS determined the Freedom of Information Act (FOIA) required it to make frequently requested materials available electronically and publicly release certain physician payment information on its website.

This information represents revenue from Medicare Part B services before the practice’s operating costs are deducted. It doesn't include information from Medicare Part A (Hospital Insurance), Part C (Medicare Advantage), Medicaid, Marketplace, or private insurance plans. The data also does not include information associated with clinical diagnostic laboratories or durable medical equipment. Further, this data set does not represent each medical practice’s entire patient panel, and it is not risk-adjusted for severity and complexity of patients treated by the physician. 

The file contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier, Healthcare Common Procedure Coding System code, and place of service.

Physicians and others can access this information by downloading files split by provider last name from the CMS web site. Alternatively, the New York Times and the Wall Street Journal have created tools to search this data by name, specialty, and city/ZIP code.

In future posts, we’ll talk about potential implications of this data release, further limitations of the data, and possible questions you may get from your patients. In the meantime, be aware that the data is out there and that CMS is not the only one looking at it anymore.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Apr 08, 2014

Another patch and more time to prepare for ICD-10

Following up last week's post, the Senate approved and the president signed a House bill that prevents steep cuts to Medicare physician payments from going into effect for one year. The bill (now law) also delays the conversion to ICD-10 diagnostic and procedure codes for at least one year.

The measure calls for a 0.5 percent increase in physician payments through Dec. 31, 2014, and no change from Jan. 1 through March 31, 2015. That means is that it will be another year before you have to worry about a potential cut in the Medicare physician payment rate. It also means that Congress has additional time to pass a permanent repeal of the Sustainable Growth Rate that has led to the current predicament. Such action in advance of the mid-term elections seems unlikely, however, given the current lack of agreement on how to pay for repeal.

On the plus side, the delay in ICD-10 does give physicians more time to prepare for that change, which will now occur on Oct. 1, 2015 (or later). Until then, everyone will continue to use ICD-9 codes. That said, you shouldn't use the delay in implementation as an excuse to delay preparation. Physicians, payers, and other users of ICD-10 should continue to move forward with preparation wherever they are in the process, and AAFP has resources to help its members do just that.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday Mar 31, 2014

SGR delay puts brakes on Medicare physician fee schedule claims

While physicians wait to see if Congress passes legislation today that avoids a 24 percent cut to Medicare payments, the continuing debate over the Sustainable Growth Rate (SGR) is already affecting claims.

The House of Representatives passed HR 4302 by voice vote on March 27. The bill would delay the SGR's mandated cuts for another 12 months. The Senate was scheduled today to take up the bill, or introduce its own version, ahead of the April 1 SGR deadline.

To give Congress more time, the Centers for Medicare & Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs) to hold claims containing services paid under the Medicare physician fee schedule (MPFS) for the first 10 business days of April (i.e., through April 14, 2014). This hold would affect only MPFS claims with dates of service on or after April 1. The hold should have minimal impact on physician cash flow because MACs under current law do not pay clean electronic claims any sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MACs will process and pay all claims for services delivered under normal procedures on or before March 31, regardless of any Congressional action – or inaction, as the case may be.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Mar 27, 2014

CMS institutes a reprieve in RAC operations

The Centers for Medicare & Medicaid Services (CMS) is in the middle of processing the next round of Recovery Audit Program contracts. To make sure the current Recovery Audit Contractors (RACs) complete their work before the current contracts expire, CMS has announced that it will wind down some of the RACs' operations.

Specifically, CMS says the RACs were to cease sending pre- and post-payment additional documentation requests (ADRs) by the beginning of March and review the ones they already have. RACs have until June 1, 2014, to send improper payment files to Medicare administrative contractors for adjustment.

As a reminder, if you have received an ADR from a RAC, you have 45 days to respond to it. The RACs, in turn, have up to 60 days to make a determination on the claim.

Besides giving the RACs time to complete their work, the CMS said the pause in RAC operations will allow it to continue refining and improving the Medicare Recovery Audit Program. For example, CMS is reviewing the ADR limits, timeframes for review, and communications between RACs and physicians. CMS has already announced a number of changes it plans to make to the RAC program with the next round of contractor awards. CMS invites physicians with additional questions to send them to RAC@cms.hhs.gov for answers.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

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