Health Care Compliance Watch : New York Health Care Compliance Lawyer & Attorney : Ilana Sable : NY Physician Representation Law

The Centers for Medicare and Medicaid Services ("CMS") have launched a series of outreach tools and social networking initiatives in an effort to effectively educate and update providers on the constantly changing rules, regulation and coverage activities affecting their practices. Below are three new informational tools that providers are encouraged to access and follow:

(1)   CMS YouTube Channel. While geared toward both beneficiaries and providers, the CMS You Tube channel features a catalog of educational videos on an array of healthcare-related topics, including Recovery Audit Contractors and Process Based Quality Improvements. The YouTube Channel is a recommended for providers looking to access basic information on key media issues.

(2)   Medicare Quarterly Provider Compliance Newsletter. The quarterly newsletter is intended to help physicians, providers, suppliers and their billing staffs understand how to avoid certain billing errors and other improper coverage activities when dealing with the Medicare Fee-For-Service program. You can find Volume 1, Issue 1 here (pdf). 

(3)   MLN Matters Articles. MLN Matters are national articles designed to inform the physician, provider, and supplier community about the latest changes to the Medicare program and are prepared in consultation with clinicians, billing experts, and CMS subject matter experts.  The MLN Matters Articles provide ready access to Medicare coverage and reimbursement rules in brief, accurate and easy to understand format and explain critical and up-to-date provider information in an effort to reduce the amount of time that providers need to incorporate these changes into their Medicare-related business functions. 

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In an effort to identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program,  The Centers for Medicare & Medicaid Services ("CMS") awarded contracts to four permanent Recovery Audit Contractors ("RAC's").  The national RAC program is the outgrowth of a successful demonstration program that used RAC's to identify Medicare overpayments and underpayments to health care providers and suppliers in California , Florida , New York , Massachusetts , South Carolina and Arizona . The demonstration resulted in over $900 million in overpayments being returned to the Medicare Trust Fund between 2005 and 2008, and nearly $38 million in underpayments returned to health care providers. 

• Overpayments can occur when health care providers submit claims that do not meet            Medicare’s coding or medical necessity policies.
• Underpayments can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed.

Health care providers that will be reviewed for overpayments and underpayments include: hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any other provider or supplier that bills Medicare Parts A and B.

On October 6, 2008, CMS announced the names of the new national RACs. The new RACs are:

• Diversified Collection Services, in Region A, initially working in Maine, New Hampshire, Vermont,  Massachusetts, Rhode Island and New York. 
• CGI Technologies and Solutions, in Region B, initially working in Michigan, Indiana and Minnesota.
• Connolly Consulting Associates, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.
• HealthDataInsights, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

Additional states will be added to each RAC region in 2009.

The RACs will be paid on a contingency fee basis on both the overpayments and underpayments they find. Contingency Fees are as follows:

• Region A - 12.45%
• Region B - 12.50%
• Region C -   9.00%
• Region D -   9.49%

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