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RACs are here to stay, says Director of Physician’s Regulatory Issues Team at CMS 
Dr. William Rogers announced last month that the Recovery Audit Contractors (RAC) project, which began as part of the Medicare Integrity Program to identify underpayments and overpayments, will continue to examine physician claims indefinitely.
“As a taxpayer, I appreciate the goal of recovering inappropriate Medicare payments. As a physician, I worry about the potential burden they might pose for physicians, from copying reams of patient records, to appealing claims when they seem to be wrong about an overpayment,” he said in a recent article issued by CMS.
Rogers is Director of the Physician’s Regulatory Issues Team at the Centers for Medicare & Medicaid Services, US Department of Health and Human Services.
In March of 2005 the Recovery Audit Contractors were announced and the contractors began examining Part A claims. They did not begin to examine physician claims until October of 2005.
In November of 2006, CMS released a RAC status report which found that the RAC process had recovered $54.1 million for the Medicare trust fund and that another $232 million had not yet been collected, but had been identified as overpayments. The report also showed that $2.5 million were identified for payment to the providers who had been underpaid.
In December 2006, Congress passed the Tax Relief and Health Care Act, Section 302 which expanded the RAC program to include all 50 states and made it a permanent program.
Since the implementation of the three-state demonstration, the Physicians Regulatory Issues Team has heard from a number of physicians who were having problems with the RAC in their state. The problems have ranged from requests for patient records that were more than four-years old (a system fix was required), to requests for an impractical number of records.
“We have worked with the RACs to fix the complaints and have found them to be proactive once they learned of a complaint,” he said.
CMS helped resolve physician issues and recommended that expanded RAC efforts would be more “physician friendly”. The draft RFP, for instance, requires that the RACs employ an MD or DO as a CMD (contractor medical director).
“We all know how we depend on our local carrier medical directors. Having a doctor in a similar role at the RAC will be of inestimable help. Look for an announcement of another major initiative that will further reduce unnecessary audits and demands,” Rogers said.
The Recovery Audit Contractor concept is here to stay, Rogers said. CMS is aware of potential problems and will work with you and the RACs to ensure that their audits are reasonable and their decisions are well informed. If you have problems with a RAC contractor, you can reach Roger’s team at: PRIT@cms.hhs.gov. |
The Practice Management Institute®
2007 Conference for Medical Office Professionals
PMI is taking its 2007 National Conference for Medical Office Professionals on the road to a city near you! Check out the best sessions from this year's national conference, plus all-new topics and presenters. You won't want to miss the hottest issues in health care today, presented by PMI's trusted faculty and local experts.
Dallas area
Oct. 31 - Nov. 1
Las Vegas
Nov. 1-2
Memphis
Nov. 8-9
Baltimore area
Nov. 8-9
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NPI Update For Physicians and Non-Physician Practitioners who Bill Medicare
Your Medicare carrier has contacted, or will be contacting you, about the date Medicare will begin rejecting your claims if the NPI and legacy number pairs used on your Medicare claims are not compatible. If you bill using only the NPI, please skip to the last paragraph.
Some incorporated physicians and non-physician practitioners have obtained NPIs as follows: an individual (Entity Type 1) NPI for the physician or non-physician practitioner and an organization (Entity Type 2) NPI for the corporation. If you enrolled in Medicare as an individual and obtained a Medicare Provider Identification Number (PIN) as an individual, and you want to use your NPI and your PIN pair in your Medicare claims, be sure you use your individual NPI with your individual PIN.
Pairing your corporation’s NPI with your individual PIN will result in your claims being rejected. If you wish to bill Medicare with your corporation’s NPI, then you must be sure your corporation is enrolled in Medicare so that it can be assigned a PIN. Please contact your servicing Medicare carrier for more information about this enrollment. Until your corporation has been enrolled in Medicare, you may continue to bill by using your individual NPI with your individual PIN to ensure no disruption in your claims being processed and paid.
Please note that similar problems may result if you bill Medicare by using your individual NPI with your corporation’s PIN (if the corporation is enrolled and has been assigned a PIN). In other words, when billing with the NPI/PIN pair, you must use compatible NPIs and PINs.
NPI-Only Billers: Make sure the NPI you are using is compatible with your Medicare enrollment. For example, if you enrolled in Medicare as an individual, then you should be using an individual (Entity Type 1) NPI. |
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Part B Drug Competitive Acquisition Program (CAP): 2008 Physician election to begin Oct. 1
The 2008 Physician Election Period for the Medicare Part B Drug Competitive Acquisition Program (CAP) will begin on October 1, 2007 and concludes on November 15, 2007.
The CAP is a voluntary program that offers physicians the option to acquire many injectable and infused drugs they use in their practice from an approved CAP vendor, thus reducing the time they spend buying and billing for drugs. The 2008 CAP program will run from January 1 to December 31, 2008.
Once a physician has elected to participate in CAP, they must obtain all drugs on the CAP drug list from the CAP drug vendor. Physicians can still continue to purchase and bill Medicare under the Average Sale Price (ASP) system for those drugs that are not provided by the physician's CAP vendor.
Additional information about the CAP is available at the following website: http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp
The physician election form can be found at the following webpage in the Downloads section. Additional information for physicians can also be found at this site: http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp
The list of drugs supplied by the CAP vendor, including NDCs, is in the Downloads section at: http://www.cms.hhs.gov/CompetitiveAcquisforBios/15_Approved_Vendor.asp
Completed election forms should be returned by mail to your local carrier, not directly to CMS. Forms must be postmarked on or before November 15, 2007.
Medicare has promised to make more information available soon.
Understanding Physician Supervision Levels
Q- Does the doctor have to be in the clinic when we take an x-ray?
A- There are three levels of physician supervision according to CMS guidelines. The physician fee schedule includes an indicator that helps to illustrate the minimum level required for each of those services. National and State Fee Schedule Database information can be found at http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp?agree=yes&next=Accept
It is important to note that documentation maintained by the billing provider must demonstrate that the required physician supervision is furnished. Services that are not performed under the appropriate supervision are not considered reasonable and necessary and, therefore, are not covered under Medicare.
An example of the requirements for a chest x-ray would be:
71020 - chest x-ray requires general supervision
71023 - chest x-ray with fluoroscopy requires personal supervision
Physician Supervision of Diagnostic Tests
General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
Personal supervision means a physician must be in attendance in the room during the performance of the procedure. This policy applies to technical components (TCs) (including TCs billed globally with the professional component (PC) of the procedure) and other diagnostic procedures which do not have relative value units reflecting physician work. These supervision requirements do not apply to diagnostic tests furnished in hospitals. |
PMI Audio Conferences Address a Variety of Current Issues
EM Coding is on the “Top 10” list of concerns for medical practices these days. It seems as though EM Coding has gotten more and more confusing over the past few years. You may find yourself racking your brain over which code to choose.
PMI agreed to host a free audio conference on October 24 in conjunction with Synergy 360 for BC Advantage magazine. BC Advantage is the only healthcare magazine dedicated to the medical billing and coding industry.
“We’ve already had more than 600 people sign up for the October conference,” said Storm Kulhan, publisher of BC Advantage. “We expect the response to be very good.”
Jimmie Hebert, CMC, CMIS, CMOM, will present the topic: EM Coding: Are You Losing Dollars? In this audio conference, Jimmie will explain a number of issues that will help take the guesswork and aggravation out of choosing the category of Evaluation and Management Service for the work your physician has performed.
Jimmie will share answers to some of the most frequently asked questions for issues such as:
* New vs. Established patient
* Consultation vs. Referral
* Inpatient Admissions
* Preventive Services
These topics and much more will be discussed. To be sure you are getting every dime your practice is legally entitled to you have got to be at the top of your game! This conference will help you achieve that goal.
The EM Coding conference offered October 24 is free, by signing up now. Please note that for this particular conference, offered free from BC Advantage, long distance charges from your long-distance carrier will apply.
To learn more about enrolling in one of PMI’s Audio Conferences, click here or call 800-259-5562. |
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Upcoming PMI
Audio Conferences
Click on a topic below for more information.
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Watch out for Medicare’s Booby Traps
Ione Broussard, CMC, CMIS, CMOM
Believe it or not, Medicare carriers do publish the Top Billing Errors and the number of occurrences. Not only do they fess-up to these errors (of course the majority of the denials are on the part of the physician) but interestingly enough they will give you the Resolution to these errors. Pretty cool, don’t you think? I found this bit of information on my local Medicare carrier’s web site.
The number one billing error in all three areas were DUPLICATES! “Claims submitted are exact duplicates of previous claims submitted. Claims often deny as duplicates for the following reasons:
- Provider refiles a claim that was previously processed and no payment was made due to a denial or the allowed amount was applied to the deductible on the initial claim submitted.
- Provider “automatically” refiles claim to seek payment if initial claim has not paid within 30 days of initial filing.
Now, I know you are thinking, no Duh! With all the denials floating around that would be the easy fix is to just resubmit but NOO! Here is what you are supposed to do:
Resolution:
1. If reason for non-payment is in question, call your carrier’s Provider Inquiry line to verify claims processing information. Don’t re-file the claim until you know a new claim is necessary.
2. Check claim status before refiling a new claim; the claim could be pending in the Medicare system for payment or pending for additional information needed to complete processing. Call the Interactive Voice Response (IVR) system to check claim status before refiling the claim.
Other common billing errors are:
- Beneficiary Eligibility
- Claim Not Covered by This Payer/Contractor
- Bundled Services
- Medical Necessity
- Non-Covered Services
- Medicare Secondary Payer (MSP)
- Place of Service
- Procedure Code/Modifier Invalid
Resolutions are mostly common sense but know that common sense does not always prevail under fire. For instance the resolution for Eligibility is: “Providers should screen their patients. Verify the Medicare number on the patient’s card…..”
Like yeah, after the fact they were seen and then it’s “Oh by the way, I do have Medicare, I think. But I can’t find my card anywhere.”
Look for effective date, see if they participate in the “replacement” HMO plan.” And of course the good ole stand by is to “call Mr. IVR”. You see, common sense is all this takes and then a computer where you have time to surf isn’t a bad tool to have either.
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© 2007 Practice Management Institute
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