HHS begins second phase of HIPAA audits The second phase of audits for compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations is underway. The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) selected a total of 167 health plans, health care providers and health care clearinghouses to be audited. Selected physician practices would have received an email from OCR on July 11. The email may be incorrectly classified as spam, so check your spam and junk folders to make sure you didn't miss it. The 2016 phase 2 HIPAA audit program is a key part of OCR’s health information privacy, security and breach notification compliance activities. The audit program allows OCR to assess covered entity compliance with the HIPAA regulations. The phase 2 audit places more attention on areas of greater risk to the security of protected health information and on pervasive non-compliance, based on OCR’s phase 1 audit findings and observations, rather than a comprehensive review of all of the HIPAA standards. OCR said that physicians selected for audits should view them as a tool to identify best practices and discover risks and vulnerabilities, not as an enforcement activity. The ultimate goal of the audits, the agency said, is to help OCR provide better guidance to the health care community. If your practice has been selected for an audit, you will need to submit the requested documentation and any written comments demonstrating your compliance with the following HIPAA requirements to OCR by July 22. The final audit report will be completed within 30 days of your response and OCR will share a copy of the final report with you. For more information about the audit, click here. August 5, 2016 General HIPAA, HIPAA Privacy Rule, Audits 0 0 Comment Read More »
DHCS expands phone system for Medi-Cal recipients in wake of critical June audit report In June, the California State Auditor’s office released a report that found the Medi-Cal phone system for beneficiaries to be “severely deficient”; the auditor urged the Department of Health Care Services (DHCS) to make upgrades. The report found that DHCS had an average of 12,500 unanswered calls each month, between February 2014 and January 2015. Some months, the telephone system rejected as many as 45,000 calls. On September 30, 2015, DHCS announced that the ombudsman phone system has been expanded. The new system is expected to improve data collection, reduce the number of dropped calls and allow patients to leave messages. The system will expand phone capacity to handle 500 calls at a time, up from the previous system's 30. Currently, about 12.2 million Californians—or about one-third of the state’s residents—receive health care coverage through Medi-Cal. That number has spiked since Medi-Cal eligibility was expanded under the Affordable Care Act. Among other key findings of the June audit were that the fact that DHCS “has not consistently monitored health plans to ensure that they meet beneficiaries’ medical needs—it did not perform any annual medical audits before 2012 and performed medical audits on less than half of the health plans in fiscal year 2013-14.” The California Medical Association continues to monitor the situation. For the full auditor's report, click here. October 14, 2015 Medi-Cal Medi-Cal, Audits 0 0 Comment Read More »
Noridian announces new audits Noridian, California's Medicare administrative contractor, has announced it will be conducting service-specific targeted audits of procedure codes 99205 and 99233 when rendered by providers with specific specialties: 99205 performed by cardiology (Centers for Medicare and Medicaid Services specialty designation 06) and pulmonary (29) 99233 performed by internal medicine (11) and hematology/oncology (83) Noridian conducts these targeted reviews based on data analysis. An analysis of these procedure codes, when performed by physicians in these specialties, indicated a higher utilization by California providers when compared to national claim payment ratios for the same services by the same specialties. These reviews are conducted on a pre-payment basis, meaning Noridian will notify physicians selected for claim audits through the additional documentation request (ADR) process before payment is made. Upon receipt of a request for information, practices must submit all applicable documentation for each claim with a copy of the ADR as a cover sheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt, or a claim denial will result. More information on the ADR process can be found here. Documentation that may support the services billed includes: Legible copy of the patient's medical record for listed date(s) of service Legible physician signature Consultation reports Physician progress notes Diagnostic test results/reports, including imaging reports if applicable Any other documentation to support the CPT Code that was billed For more assistance on signature and documentation requirements, refer to the Documentation Guidelines for Medicare Services on Noridian’s website. Noridian will review the documentation submitted within 30 days of receipt. No letters will be sent on the outcome of each individual claim. The claim decisions will be reflected in the remittance advice and may be appealed through the normal appeal process, if unfavorable. When the audit is complete, Noridian will analyze the results and determine if any subsequent actions are necessary. The results will be posted to Noridian’s JE Part B website. August 5, 2015 Medicare Medicare, Noridian, Audits 0 0 Comment Read More »
California Medical Association supports the Fair Medical Audits Act of 2015 The California Medical Association (CMA) issued a strong endorsement for the “Fair Medical Audits Act of 2015,” introduced today by U.S. Representative George Holding of North Carolina. The legislation addresses many concerns that physicians have with regard to the extraordinary lack of transparency and expensive, time-consuming and often unfair processes that plague the current Medicare audit program. Representative Holding declared it time to fix the broken audit program: “Put simply, patients achieve the best health outcomes when practicing physicians do just that – practice medicine. My bill will bring transparency and fairness to the audit process so doctors can spend more time caring for their patients and less time proving their innocence. Medicare frauds must be found and severely punished, but not at the cost of the independent practice of medicine.” Currently, Medicare pays recovery audit contractors (RAC) on a contingency basis to find overpayments to health care providers, providing these contractors with undue monetary incentives to audit doctors. This legislation would establish incentives for RACs to make more accurate audit findings and increase educational efforts to help physicians avoid common mistakes. Since its inception in 2006, CMA has worked closely with the Physicians Advocacy Institute to advocate for more fair and transparent medical audits. CMA President Luther F. Cobb, M.D., lauded the legislation, noting: “It is time to address fundamental problems that have contributed to the backlog of audit appeals and caused a great deal of unnecessary expense and confusion for physicians in California.” Robert W. Seligson, President of the Physicians Advocacy Institute and EVP/CEO of the North Carolina Medical Society, also hailed the proposal, stating, “Physicians and their advocates across the nation commend Congressman Holding for his leadership on this critically important issue.” Representative Holding is a member of the House Ways and Means Committee, which has jurisdiction to consider legislation to reform the RAC program. For more information, please contact CMA’s Molly Weedn at (916) 551-2069, or PAI Executive Vice President Kelly Kenney at (312) 543-7955 or k2strategiesllc@gmail.com. May 26, 2015 Medicare Federal Legislation, Medicare, Recovery Audit Program, Advocacy, Audits 0 0 Comment Read More »
Medicare RAC court case keeps collections on uncertain footing The U.S. Court of Appeals for the Federal Circuit issued a decision in early March in a case filed by one of the Medicare Recovery Audit Contractors (RAC) after the Centers for Medicare and Medicaid Services (CMS) changed the timing for the payment of contingency fees on collections. The decision means the auditing program will be put on hold until CMS determines how to contract with its RACs. The RAC program is responsible for identifying fraud and waste in the Medicare system by detecting improper Medicare payments. Since 2008, when the program started, RACs have been paid immediately after Medicare overpayments are collected from providers – generally within 41 days. In 2014, CMS proposed a different payment method: paying on collections only after a provider's challenge passed the second of a five-level appeal process. RACs balked at this because providers often appeal the overpayment decisions, causing contingency fees to be delayed anywhere from four months to more than a year. CMS also required the RACs to create a reserve fund, to be used to repay CMS any contingency fees related to denials overturned on appeal. The original RAC contracts did not include a provision to handle such scenarios after RAC contacts expired. RAC contractor CGI filed a lawsuit in federal court protesting against the new payment terms, arguing that CMS violated federal procurement law by delaying payments to the RACs beyond fair and usual practices. The CGI lawsuit asked the court to compel CMS to procure new contracts through a time-consuming request-for-proposal process instead of more straightforward commercial bidding. The federal appeals court agreed with CGI's protest, and now CMS must decide how it wants to contract with RACs. The agency can either rebid the contracts through the general commercial process with the original contingency fee structure from 2008, or it can rebid the contracts through the longer noncommercial process with the new payment terms. This will cause a significant delay for the new contracts and it is likely that they won’t be finalized until early 2016. Physicians and hospitals got a reprieve last year from the RAC auditing program, while CMS reevaluated its contracts and implements improvements for physicians. Audits were to begin again in the fall of 2015. The Medicare program has already felt the effects of the scaled-back RAC program, only recouping $48.3 million of overpayments from providers – approximately $768 million less than what RACs collected in the same period the year before. March 18, 2015 Medi-Cal, Medicare Centers for Medicare and Medicaid Services, Medicare, Recovery Audit Contractor, Audits 0 0 Comment Read More »
Medi-Cal audits began in September The California Department of Health Care Services (DHCS) has begun post-payment claims review of Medi-Cal claims in California. The purpose of this audit is to identify and correct improper Medicaid payments through the collection of overpayments and reimbursement of underpayments made on claims for health care services provided to Medicaid beneficiaries. The program will enable the Centers for Medicare and Medicaid Services (CMS) to implement actions that will prevent future improper payments in all 50 states. DHCS has contracted with Health Management Systems, Inc. (HMS) to act as the Recovery Audit Contractor (RAC) for the State of California. HMS will perform desk and field audits for selected fee-for-service Medi-Cal claims paid within the last three years to determine if claims were paid correctly. HMS will contact providers whose claims have been selected for review. After the initial contact, providers may receive letters from HMS requesting medical records for further review. These letters, which should specify HMS’ preliminary results will be coming out no earlier than October. DHCS is urging all providers to comply with requests for medical records from HMS. If you fail to submit the requested records, it will be considered a valid overpayment and you will be required to refund the claim payment amount to DHCS. Your cooperation will help ensure that the audit results are accurate and that California retains its much-needed federal matching monies for the Medi-Cal program. For more information about the audit and what to expect from the contractor, see the HMS Medicaid RAC website. Providers can also contact HMS Provider Services at info@hms.com or (855) 699-6290. For more information on Medi-Cal audits, see CMA On-Call document #7201, “Medi-Cal Audits.” Contact: CMA’s reimbursement help line, (888)401-8911 or economicservices@cmanet.org. September 18, 2014 Medi-Cal Department of Health Care Services, DHCS, Medi-Cal, Audits 0 0 Comment Read More »
CMS must provide better oversight to prevent duplicate audits says GAO study A newly released study by the federal General Accounting Office (GAO) found that the Centers for Medicare and Medicaid Services (CMS) needs to provide better oversight and guidance for provider payment auditors to prevent duplicative post-payment claims review audits. Several types of Medicare contractors conduct postpayment claims reviews to help reduce improper payments: Medicare Administrative Contractors, which process and pay claims; Zone Program Integrity Contractors, which investigate potential fraud; Recovery Auditor Contractors, tasked with identifying on a postpayment basis improper payments not previously reviewed by other contractors; and the Comprehensive Error Rate Testing contractor, which reviews claims used to annually estimate Medicare's improper payment rate. The report notes that although CMS implemented a database to track audit activities, designed in part to prevent duplicative audits by multiple contractors, it must do more to ensure that auditors are not completing duplicative reviews. The report notes that the database was not designed to provide information on all possible duplication, and found that it's data is not reliable because other postpayment contractors do not consistently enter information about their reviews. The report concludes that CMS has not provided sufficient oversight of this data or issued complete guidance to contractors on avoiding duplicative claims reviews. GAO recommends that CMS take actions to improve the efficiency and effectiveness of contractors' post-payment review efforts, which include providing additional oversight and guidance regarding data, duplicative reviews and contractor correspondence. In its comments, the U.S. Department of Health and Human Services concurred with the recommendations and noted plans to improve CMS oversight and guidance. Click here to read the full report. August 21, 2014 General CMS, Insurance/Reimbursement, Medicare, Audits 0 0 Comment Read More »
