Thanksgiving Fare: CGI, AMA, Qui Tam, and More ADRs

That's One BIG Turkey

The ACA Float in the Macy’s Thanksgiving Day Parade

Hospitals Deal with CPT, ASC, ICD, and DRG; but HHS/CMS Still Can’t Deal with CGI?

Despite the fact that producing inaccurate pricing is considered “fraud” when providers do it, evidently HHS does not consider it to even be bad form, much less fraud, to provide hugely inaccurate prices when they quote healthcare plan premiums via the Healthcare.gov website. The contractor responsible for the site is CGI, who is also the Medicare Region B RAC. How comforting this must be… for those providers in RAC Region B. CGI must really know how to make good decisions, yes? Maybe not. Evidently, when browsing exchange plans sold via the troubled site, visitors are repeatedly told that “the final premium you pay may be lower, perhaps much lower, than the prices shown.” The site seems unable to perform estimates using the most obvious (and critical, for pricing calculations) personal attributes. You know… little things like AGE or even TOBACCO USE. One wonders, then, if the same managers at CGI are involved when RAC denials are being decided by CGI reviewers. At any rate, there appears to be no drawback to being inaccurate (there are no penalties and CGI cannot be fired), as long as you are a CMS contractor. Only providers get penalized for making errors. See Healthcare.gov estimates may be misleading

Observation at the AMA

By now, I would hope that all my readers know that there is no such thing as “observation status” — only observation services, which are only billable for a patient in outpatient status. Nevertheless, even the learned writers in the JAMA do not seem to understand the distinction. A recent spate of articles seem to make that much clear. Hopefully, the conclusions reached do not depend upon such a distinction and may still prove helpful. To wit… According to a study published in JAMA Internal Medicine“Observation status” [sic] patients cost hospitals more money than admitted inpatients. Data from the University of Wisconsin Hospital and Clinics in Madison show observation care resulted in an average loss of $331 per patient, while inpatient care resulted in an average profit of $2,163 per patient. See ‘Observation Status’ Patients Cost More Than Those Admitted, Study Finds

More Disturbing: 2 Midnights = Losses

Another article, also just published in JAMA Internal Medicine, found that under the new IPPS rules, the total reimbursement gains offered by the newly reclassified inpatient stays would be dwarfed by the decreased reimbursement from newly reclassified outpatient stays. For the 566-bed hospital studied, the bottom line would lose an astounding $22 Million, over 18-months. See ‘Observation Status’ for Hospitalized Patients: Implications of a Proposed Medicare Rules Change

AND… Whistleblowers Gain Support from CMS

While only 62 healthcare qui tam cases were filed from 1987 to 1992, there were 417 filed in 2011 alone, and another 412 filed in 2012, according to a study from Washington, D.C.-based Taxpayers Against Fraud. In April 2013, CMS proposed a rule that would increase incentives for whistleblowers who provide information that leads to the recovery of improper Medicare payments. See The Growth of Healthcare Fraud Qui Tam Lawsuits

AHA’s Lastest RACTrac Findings

The AHA published its latest report on RAC activity in their 3rd Quarter Results for RACTrac. Yes, RAC records requests and audits were sharply increased over the 1st Quarter of 2013, but this is no surprise. There were, however, a couple of surprising figures reported by AHA:

  • 94% of hospitals that appealed claims reported delays beyond the statutory 90-day-limit for an ALJ determination;
  • 71% of all appealed claims are still sitting in the appeals process;
  • 43% of participating hospitals reported having a RAC denial reversed in the discussion period.

Other findings were not surprising, such as the finding that 64% of short-stay “medical necessity” denials were issued because care was “provided in the wrong setting” and not because the care was “medically unnecessary.” See AHA: Hospital RAC Audits Rising

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