CACS, MACS & RACS WHAT TO EXPECT IN 2009

Transcription

1 . CACS, MACS & RACS WHAT TO EXPECT IN 2009 Presented to GASCO University December 3,

2 Presented by: Karen Beard Director Georgia Society of Clinical Oncology 2

3 Medicare Carrier Advisory Committee (CAC) Georgia s Part B Carrier is CAHABA GBA. The region covered by CAHABA has included Alabama, Georgia and Mississippi Until early 2005, all three states had 3 separate Medical Directors and three sets of Local Carrier Determinations affecting oncology. Medicare law requires a CAC for each state, but only 1 medical director per jurisdiction 3

4 GASCO s Relationship with The Georgia CAC Meetings are at least 3 times per year in Atlanta During that time GASCO can: discuss comments to draft LCDs; request revisions to existing LCDs; and bring additional oncology specialists to provide comments or scientific data on oncology related topics. Provide information on early release of trial results Answer MD questions on off label use appeals Note: Local Carriers cannot make any coverage decision exceptions or modifications to a National Carrier Decision (NDC) 4

5 GASCO s Relationship with The Georgia CAC GASCO Provides 2 representatives and alternates to the CAC for hematology, oncology and a special advisor for radiation oncology Due to the rapid changes in cancer related diagnostic and therapeutic medicine, GASCO has maintained a relationship with the Part B Medical Director. This role now being handled by 1 Medical Director - Dr. Greg McKinney - His AA, Kathy Thomas, can be reached at 205/ is gmckinney@cahabagba.com 5

6 Changes in the LCD Approval Process In 2005 CAHABA replaced individual state LCDs with consolidated LCDs applicable to all 3 states The policy gains previously won by GASCO had to be revisited for over 25 oncology policies & additional polices with oncology diagnosis codes e.g. New consolidated policy for Complete Metabolic Panel left off a large number of cancer ICD codes contained on previous policies. 6

7 Preparation for CAC Meeting GASCO obtains the draft LCDs usually a month before the CAC meeting for all draft LCDs to see if hem/ onc is affected. GASCO s ChairmanDirector analyzes changes from previous LCDs and distributes the drafts to GASCO s Clinical Practice Committee (MDs, Nurses, Pharmacists, Administrators) Copies are sent to the CAC members for Mississippi and Alabama. GASCO collects comments from all three states and sets a conference call for all 3 states to discuss any differences in advance of the State CAC meetings 7

8 Results Presents a more consistent and organized method of addressing policy issues High level of trust between GASCO & Carrier Medical Director Direct contacts for Medicare policy staff often with same day responses on issues Creates a model for cooperation during future CMS consolidation 8

9 LCD Retirements Contractors will retire when data show not as important does not mean LCD is incorrect Responsibility for correct performance, coding, billing and medical necessity under Medicare, remains with provider offices Responsibility for correct claims submission is unchanged whether or not an LCD is in place 9

10 CMS Part A&B Consolidations Important to reach out to other Societies in new MAC regions for consensus on LCD recommendations during consolidation So far the LCD accepted for most jurisdictions has been the least restrictive This can change based on bid winner s philosophy 10

11 New A/B MAC Jurisdictions = Start-up 2 N = Cycle One 9 N = Cycle Two 1

12 Medicare Contracting Reform RFP (3/05) Award (12/05) Cutover (7/06) Start-up Cycle RFP (9/05) Award (6/06) Cutover (7/07) 4DMEMACs On Hold 1 A/B MAC Start-Up = J3 Cycle One Cycle Two RFP (9/06) Award (9/07) Cutover (9/08) 7 A/B MACs Cycle One RFP (9/07) Award (9/08) Cutover (7/09) 7 A/B MACs Cycle Two 4 HH MACs 1/2005 1/2006 1/2007 1/2008 1/2009 1/2010 MAC Procurement MAC Transitions 12

13 Medicare Contracting Reform Where A/B MAC contract awards stand now: Jurisdiction 3 ( J3 ) to Noridian in 2006 J4 awarded to TrailBlazer Health Enterprises J5 awarded to Wisconsin Physician Service (WPS) J1 to Palmetto GBA- Protested; resolved for Palmetto J12 to Highmark Protested; resolved for Highmark J13 to National Government Services (NGS) J2 to National Heritage Insurance Corp (NHIC) J7 to Pinnacle Business Solutions, Inc. (PBSI) J9 to First Coast Service Options J14 to National Heritage Insurance Corp (NHIC) 11/18 GA/TN/AL J10 Due by 10/08 - Delayed Remaining 4 A/B MACs to be awarded thru 2009 DME MAC awards have been pit on hold 13

14 Medicare Fee-For For-Service Program Administrative Functional Environment

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16 Recovery Audit Contractors (RACs) Improper Payment Information Act requires federal agencies to measure and reduce improper payment rates Improper payments include overpayments underpayments 16

17 Office of Management & Budget (OMB) 8 Agencies = 88% of overpayments $1.8 B Food Stamp Program $1.4 B National School Lunch Program $2.5 B Old Age Survivors' Insurance Unemployment Insurance $4.1 B Supplemental Security Income $12.9 B Medicaid $6.7 B Other $10.8 B Medicare $11.4 B Earned Income Tax Credit Medicare receives over 1.2 billion claims per year. This equates to: 4.5 million claims per work day 574,000 claims per hour 9,579 claims per minute 17

18 RAC Legislation Medicare Modernization Act, Section 306: required RAC demonstration Demonstration March 2005 March 27, 2008 Tax Relief and Health Care Act of 2006, Section 302: requires permanent and nationwide RAC program no later than 1/1/2010 TEMPORARILY ON HOLD DUE TO CHALLENGES 18

19 Recovery Audit Contractors (RACs) CMS pays each RAC on a contingency fee basis; i.e. a percentage of what the RACs identify and collect from providers. 1 st time the Medicare program has ever paid a contractor on a contingency fee basis for claim review and overpayment collection work! 19

20 RAC Administrator Awards & Fees Connolly Consulting (Connolly) (Georgia s administrator) 9% Health Data Insights (HDI) 9.49% Diversified Collection Services, Inc. (DCS) % CGI Technologies 12.5% 20

21 RAC contract includes the following tasks 1. Identifying Medicare claims that contain non-msp underpayments for which payment was made under part A or B. 2. Identifying and Recouping claims that contain non-msp overpayments for which payment was made under part A or B. Includes corresponding with the provider. 21

22 RAC Tasks - continued 3. For any RAC-identified overpayment that is appealed by the provider, the RAC shall provide support to CMS throughout the administrative appeals process and, where applicable, a subsequent appeal to the appropriate Federal court. 4. For any RAC-identified vulnerability, support CMS in developing an Improper Payment Prevention Plan to help prevent similar overpayments from occurring in the future. 22

23 RAC Tasks - continued 5. Performing the necessary provider outreach to notify provider communities of the RAC s purpose and direction. NOTE: The proactive education of providers about Medicare coverage and coding rules is NOT a task under RAC statement of work. CMS has tasked QIOs, FIs, Carriers, and MACs with the task of proactively educating providers about how to avoid submitting a claim containing a request for an improper payment. 23

24 How RACs Select Claims Choose areas of focus based on data mining techniques, OIG & GAO reports, CERT reports & experience and knowledge of staff Two types of review (depending on certainty) Automated (no medical record) Certainty Complex (medical records reviewed within 60 days)- No certainty New Issues for review will be posted to RACs website 24

25 RAC Review Process Use same Medicare policies as FIs, Carriers and MACs: NCDs, LCDs & CMS manuals Use same types of staff as FIs, Carriers and MACs: nurses, therapists, certified coders & physician CMD 25

26 Summary of Medical Record Limits (for FY 2009) Inpatient Hospital, IRF, SNF, Hospice 10% of avg mthly Medicare claims (max of 200) per 45 days Other Part A Billers (Outpatient Hospital, HH) 1% of average monthly Medicare services (max of 200) per 45 days Physicians Solo Practitioner: 10 medical records per 45 days Partnership of 2-5 individuals: 20 medical records per 45 days Group of 6-15 individuals: 30 medical records per 45 days Large Group (16+ individuals): 50 medical records per 45 days 26

27 Assuring Accurate Decisions New Issue Review CMS will review all new issues proposed for review by the RAC Validation Process Validation Contractor will review a random sample of each RACs completed reviews CMS will release an accuracy score for each RAC on an annual basis Appeal Process If RAC loses on any level of appeal, RAC pays back contingency fee 27

28 Medicare Payments Affected by RACs - Cumulative through 9/30/07 $239.2 b Medicare Payments Unaffected by RACs 99.8% $436.1 m Medicare Payments Found by the RACs to be Improper 0.2% 28

29 FY 07 Findings Overpmts Collected: $357.2 m Less Underpmts Repaid: - ($14.3 m) Less $ Overturned on Appeal: - ($17.8 m) Less Costs to Run Demo: - ($77.7 m) BACK TO TRUST FUNDS $247.4 m 29

30 FY 07 Findings Overpayments Collected by Provider Type Most overpayments were collected from inpatient hospitals 6% Outpatient Hosp $22.6m 88% Inpatient Hosp/ SNF $312.8m 3% 1% 2% Physician $12.2m Amb, Lab, Oth $4.1m DME Supplier $5.5m SOURCE: RAC Data Warehouse 30

31 FY 07 Overpayments Collected by Error Type (Net of Appeals) Most improper payments occur when providers submit claims that don t comply with Medicare coding rules or medical necessity guidelines 17% Other 42% Incorrectly Coded 9% No/Insufficient Documentation SOURCE: Self-reported by RACs RAC Findings Similar to CERT Findings CERT found that: 25.6% of the error rate was due to No/Insufficient Documentation errors 33.3% of the error rate was due to Medically Unnecessary errors 38.4% of the error rate was due to Incorrect Coding errors 5.1% of the error rate was due to Other errors 32% Medically Unnecessary Service or Setting 31 31

32 Top Services with RAC-Initiated Overpayment Collections Claim RACs Only Type of Provider Description of Item or Service Location of Problem Inpatient Hospital Surgical procedures in wrong setting (medically unnecessary) NY Excisional debridement (incorrectly coded) NY, FL, CA Cardiac defibrillator implant in wrong setting (medically unnecessary) FL Treatment for heart failure and shock in wrong setting (medically unnecessary) NY, FL, CA Respiratory system diagnoses with ventilator support (incorrectly coded) NY, FL, CA

33 Top Services with RAC-Initiated Overpayment Collections Claim RACs Only Type of Provider Description of Item or Service Location of Problem Inpatient Rehabilitation Facility Services following joint replacement surgery (medically unnecessary) CA Skilled Nursing Facility Services for miscellaneous conditions (medically unnecessary) Physical therapy and occupational therapy (medically unnecessary) CA CA Outpatient Hospital Speech-language pathology services (medically unnecessary) Neulasta (medically unnecessary) CA NY, FL Speech-language pathology (medically unnecessary) NY, CA Infusion services CA

34 Top Services with RAC-Initiated Overpayment Collections Claim RACs Only Type of Provider Description of Item of Service Location of Problem Physician Pharmaceutical injectables (incorrect coding, wrong units) NY, CA Neulasta (medically unnecessary) NY Vestibular function testing (other error type) FL Duplicate claims (other error type) CA Durable Medical Equipment Items during a hospital inpatient stay or SNF stay (other error type) NY, FL, CA Lab/Ambulance/Other Ambulance service during hospital Inpt stay FL, CA

35 National Expansion Schedule A D B Summer 2008 Fall 2008 Jan 2009 or later C All dates are flexible Names of new RACs will be announced in: TBD

36 RAC Expansion To All MAC Areas by 1/01/2010 Look-Back to be three years Oldest look-back to be 10/1/ 2007 No RAC review of claims previously in appeal or complex review such as by Carrier, MAC, PSC, CERT Six month blackout period from 3 months before a MAC transition until 3 months after 36

37 Medicare Enrollment Changes 1/1/2009 PLAN AHEAD FOR NEW ASSOCIATES & BUY-INS CMS has re-defined the effective date of billing for physicians & NPPs as the later of these two dates (1) the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor versus (2) the date an enrolled physician or non-physician practitioner first started furnishing services at a new practice location. Approved apps for Physicians and NPP may only bill retrospectively for services furnished up to 30 days prior to the effective date instead of the 23 months allowed under current regulations. 37

38 Medicare Enrollment Changes 1/1/2009 The rule requires physicians & NPPs to report any changes of ownership, adverse legal actions, or change in practice location within 30 days (versus the current 90 days) or face revocation of Medicare billing privileges and the recoupment of Medicare payments from the date of the reportable change. 38

39 For more information contact: Karen Beard Director/GASCO 3330 Cumberland Blvd, Suite 200 Atlanta, GA Toll Free (877) 88GASCO Fax: (770)