News from the Week of February 28

The Pause Expands

Some pauses are truly refreshing... just not this one.

Some pauses are truly refreshing… just not this one.

Last Month, CMS extended the pause (I refuse to call it a moratorium) on RAC reviews of Medicare claims under the  2 Midnight Rule to a full year, from Oct. 1, 2013 to Sept. 30, 2014. MACs, however, will be able to conduct such reviews, and when errors are found, the MACs will be responsible for educating providers as to the correct application of the two-midnight rule – as if they know how to apply the rule.

An article in “Inside Patient Finance” poses the idea that this pause is simply a tactic to reduce ALJ appeals. The article claims that providers accuse the RACs of erring too often when they issue denials, as evidenced by the overturn rate at the ALJ level – which is now totally clogged with appearls, too many for the OMHA to handle.

See the full article for more details.

Credits: Will Moratorium on RAC Reviews of Two-Midnight Rule Offset Medicare Appeals Backlog?

RACs Also Paused

Two Centimeters to the left would be MUCH better

Two Centimeters to the left would be MUCH better

CMS claims that it will overhaul the controversial RAC system and announced a series of changes that will are to be included in the new RAC contracts.

Also, as of Friday Feb 21, CMS suspended the current RACs from issuing Additional Documentation Requests (ADRs) to providers, and will suspend the ability of Medicare Audit Contractors to send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration on March 1.

Current RACs also must stop sending improper payment notices to the MACs by June 1.

NOTICE: Automated denials will, therefore, continue, until June 1. (Thanks to Sharon Easterling for pointing that out!)

See the full article for more details.

Credits: CMS Announces Halt to RAC Activities, Prepares for New Contracts

So Is All This Legal?

2240.stripAn attendee at the OMHA Forum on February 12 asked the question of Chief ALJ Nancy Griswold, “What is the legal basis of your decision to suspend assigning cases to Judges?” (my précis of the question), and the Honorable really had no answer. I’m waiting with bated breath for someone to file a lawsuit about it.

Meanwhile, after President Obama “tweaked” the ACA by letting people with canceled policies keep their coverage for another year, there is interesting discussion about how all this can or cannot be done.

Credits: So many changes to the healthcare law, but are they legal?

A Good Case FOR A Contingency Fee?

The bigger question is... what results are we looking for?

The bigger question is… what “Results” are we looking for?

Our government, in years past, has resorted to hiring private corporations to do auditing and get paid based upon their outcomes – sound familiar? That’s what a contingency fee does. You provide an outcome that I can measure, and I pay you based on that measure – a percentage of the outcome.

While this tactic is widely used by the government, Federal Judges have found it to be unconstitutional in cases that involve auditing for taxes. But in other situations, it is either not being challenged or has survived legal challenge.

That said, I did just see a situation where I would be more than happy to accept a 10% contingency fee if they would pay me to fix a glitch in a program in the state of Maryland that will cost over $30 Million over the next two years. Why don’t our bureaucrats use this type of tool to fix problems that are known and real and indeed fixable, without resorting to subjective, questionable decisions being made by underpaid auditors in ill-concieved auditing programs?

See the article to find the example that I think is a good candidate for an outcome-based contract plan, and might be a model for plans capable of returning more into the Trust Fund than the RACs.

Credits: Maryland Exchange Can’t Tell Whether Medicaid Enrollees Are Still Eligible

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