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Every Hospital and Provider Needs to Understand the Mais Decision

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Last month, on November 7, 2014, the WUSB 90.1 radio show, The Business of Healthcare with host Susan Montana, featured guest Laura J. Lowenstein, Esq.
The interview and discussion was based on Laura’s article posted on her website with the title “Every Hospital and Provider Needs to Understand the Mais Decision”

LISTEN to the Radio Program on archive:

Be sure you don’t miss the next radio show that is all about “The Business of Healthcare” with host Susan Montana on 90.1 fm WUSB

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What’s the Difference Between an Audit and a Review?

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So you’ve selected which type of internal audit/review you’re going to conduct for your practice.  Now you need to determine if you’re going to do an audit or a review.  What is the difference you may ask?

Audit

An audit is conducted after claims have been submitted to a payor.  The advantages are that a claim has gone through the entire process, and the analysis can include how the payor adjudicated the claim.  It allows for a complete picture of the results of the service delivered by the provider.  This will let you know which services a payor:

·        bundles or unbundles

·        up or down codes

·        pays, and how much

·        denies, and for what reason

A primary disadvantage to performing a claims audit is that if problems are discovered, they have already been submitted to the payor so you may need to:

·        submit voids or adjustments to correct billing errors

·        self-report compliance errors

Review

A review is performed before any claims are submitted to the payor.  It allows for the discussion and research of any issues that arise, and the capture of any additional supporting documentation that may not have been included in the initial submission.  Of course, care must be taken to ensure documentation is not improperly supplemented.  Provider notes may not be altered, studies that were not reviewed by the provider at the time of service are not admissible, etc.

Performing a review enables you to make any coding or billing corrections prior to submitting claims, avoiding the need to submit claim corrections.

A review also offers the practice an opportunity to discuss any issues identified to determine the course of action to take.  This is particularly important when documentation deficiencies deem a service unbillable, or when a compliance issue is identified.

A disadvantage of performing a review instead of an audit is that you don’t have a full picture of the impact of the service provided on the practice.  Without seeing how the payor adjudicates the claim, valuable insights into the bottomline net results are missed.

 

Which type of process makes the most sense for your practice?  Weigh the pros and cons of each, and give us a call

If you’ve got any questions or need help selecting a chart review method.  Contact us at sue@habaneroinc.com. 

Be Your Own Medical Record

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It started as a professional curiosity, but now it has become a habit, and I recommend it to everyone.  Maintain your own medical record.

I’ve found this helps me better understand what is going on with my own health, and it also makes it easier to communicate amongst the various healthcare practitioners you may see over the years.

Medical filesFor example, I recently went for a DEXA scan for bone density. It’s something that is recommended, especially for women, and especially for women with bone issues. My GYN had ordered the test, and when I went to have it done, I asked the technician for a copy of the scan and she printed it out right then and there.  Same thing when I had some 3D dental xrays taken a few months ago.  It made it easy for me to get second opinions, and eliminate a potentially unnecessary over exposure to another xray.

I suggest maintaining copies of all your blood results too.  This can help you when you are doing your own research into health related topics, be it research into traditional or alternative medical topics.

You may also want to consider doing this for any children, friends or relatives for whom you have, or may have, responsibility for.  For example, if an elderly relative were suddenly in need of medical care, would you be able to provide a list of their medications to emergency responders?

The bottom line, in today’s healthcare arena, we all need to be proactive in taking care of our health and the health of our loved ones.  As in many other areas of life, information is power!

– As published in GEM Magazine. Author: Susan Montana

Please direct your health care reimbursement questions or topics you would like to know more about to Sue@HabaneroInc.com.

The RAC Attack

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Many medical practices are feeling the impact of the Medicare Recovery Audit Contractor (RAC) process, especially as non-Medicare payors have gotten on the band wagon.  It is difficult enough to submit claims and receive payment for all the services you provide, but now they want to take back payments – sometimes years later!

What can be done to keep as much of these payments as possible?  The key is to have a formal process in place, and to be diligent about time limits and attention to detail.

What is a RAC?

Medicare began recovering overpayments from hospitals via RAC in 2005.  It began witha demonstration project in four states, and was rolled out to all providers in all 50 states in 2009.  The RAC is paid a contingency fee — a percentage of the money it recovers for the CMS.  Therefore, it is in the Contractor’s interest to cast the widest net possible.

What types of audits/reviews are there?

There are many categories of insurance recoveries.  Upon receipt of a letter from a payor, your first step is to determine the type of request.  Examples of some types of audits/review are:

  • RAC – The Recovery Audit Contractor for Region A — which includes New York — is Diversified Collection Services, Inc.
  • COB – Coordination of Benefits, where the insurer believes another party was responsible for payment of the claim.
  • Global reviews – Medicare implements a global review when sample reviews identify gross provider errors for a particular procedure code.
  • Targeted reviews – insurers and/or their contractors perform sophisticated data analyses to determine certain provider’s billing practices are outside the norm.

What should I do?

The most important thing to keep in mind is that there are very strict timeframes for responding to insurance recovery requests.  Penalties for not responding can be significant, including charging interest, and sending unpaid requests to a collection agency.

There are two schools of thought regarding a response strategy.  The first is to challengeeverything, and the second is to only challenge those cases where responding is cost justified.  There are valid arguments for each position.

Even if you do not intend to challenge each insurance recovery request, it is essential to keep copies of all letters received, and any checks or other responses submitted.  It is also recommended to keep a log of all recovery requests for quick reference.

– As published in GEM Magazine, Author: Susan Montana

Habanero, Inc., based in Patchogue, NY provides healthcare reimbursement consulting services to medical practices – helping them maximize reimbursement, maintain compliance and optimize operational efficiency. Ms. Montana may be reached at 631-244-5661 or SMontana@HabaneroInc.com.