Medicare is Auditing You! What To Do Next?

by Mary Pat Whaley http://www.managemypractice.com/

There are a number of different audits that are carried out by Medicare-contracted auditors. It’s important to know the differences and have a plan for responding. CERT stands for Comprehensive Error Rate Testing and CERT audits were initiated in 2000. The program is responsible for measuring improperly paid claims. The CERT Program uses the following OIG-approved methodology: A sample of approximately 120,000 submitted claims is randomly selected; medical records from providers who submitted the claims are requested; and the claims and medical records are reviewed for compliance with Medicare coverage, coding and billing rules. RAC stands for Recovery Audit Contractor and began in early 2009. The RACs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions to stop future improper payments. RAC is currently focusing on inpatient services and physical therapy services. As of the date this post was published RAC was not focusing on physician services. ZPIC (Zone Program Integrity Contractors) replaces the Medicare Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) that are currently in use by CMS. ZPICs are be responsible for detection and deterrence of fraud, waste and abuse across all claim types. ZPICs have access to CMS National Claims History data, which can be used to look at the entire history of a patient’s treatment no matter where claims were processed. Being able to look at the overall picture will enable them to more readily spot over billing and fraudulent claims. Among other things, ZPICs will look for billing trends or patterns that make a particular provider stand out from the other providers in that community. Once a ZPIC identifies a case of suspected fraud and abuse, the issue is referred to the Office of Inspector General (OIG) for consideration and possible initiation of criminal or civil prosecution. ZPIC is widely considered to be the greatest threat to physician practices. Seven ZPIC zones have been identified. The zones include the following states and/or territories and most have been assigned contractors: Zone 1 – CA, NV, American Samoa, Guam, HI and the Mariana Islands http://www.safeguard-servicesllc.com Zone 2 – AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NE, KS, IA, MO http://www.csc.com/advancemed Zone 3 – MN, WI, IL, IN, MI, OH and KY Zone 4 – CO, NM, OK, TX. healthintegrity.org Zone 5 – AL, AR, GA, LA, MS, NC, SC, TN, VA and WV http://www.csc.com/advancemed Zone 6 – PA, NY, MD, DC, DE and ME, MA, NJ, CT, RI, NH and VT Zone 7 – FL, PR and VI http://www.safeguard-servicesllc.com How should you respond to a Medicare audit? Log all requests for records from all payers. Time and date all communications received and all communications sent. Scan all records sent and include a cover letter itemizing contents of response. Send records via certified mail. If you get a request for a large amount of records at one time, consider getting advice from a consultant or attorney who specializes in Medicare audits as a large scale record request may cripple the practice operations. How can you be proactive before you get an audit letter? Check the audit sites monthly to see if your specialty or any services you provide are being targeted for an audit. CERT – www.cms.hhs.gov/cert Check the ZPIC site for your zone above OIG – www.oig.hhs.gov/reports.html Check your RAC site in my post here Conduct an internal assessment to identify if you are in compliance with Medicare rules or hire a third-party to conduct an audit for you. Identify corrective actions to promote compliance. Appeal when necessary Excellent resource site http://www.willyancey.com/sampling-claims.html Related posts: The Cohen Report: Free Webinar on Auditing the RAC Auditors NOTE: If you need the basics on RACs, click here... Dear Mary Pat: How Do I Handle Chart Audit Requests From Payers? When a payer or health plan calls your practice and... Congress Expected to Further Delay SGR Cut to Medicare Physician Fee Schedule UPDATE: On June 24, 2010 the House and Senate passed...

View article...

Urgent - 2011 CMS Updates Now Available for DataPlus

2011 CMS Updates Now Ready for DataPlus Clients!

Greetings! The 2011 CMS Updates are now available for download into DataPlus. These updates include: RVU's Medicare Fee Schedules CPT Codes ICD-9 Codes Exempt Codes it is very important that you update your system, in order for your data to reflect current information! Simply follow the steps below to update your database. This update can be done from ANY computer that runs DataPlus (it does not need to be run from the server). HealthPort users MUST complete this process BEFORE YOU START JANUARY Month end procedures!!! Please contact our support team with any questions by phone at 888.688.3282 or email at support@mydataplus.com.

To Perform your update... NOTE: You MUST have administrator rights to perform this update. From the DataPlus main menu: Select Utilities Select Check for CMS Updates Select Continue CMS updates that are available to download will have a check mark next to them Select continue You will see a Processing bar for each update You will see "Updated" in blue lettering when the update(s) are complete Select OK HealthPort Users: Data will not show on reports until after you have completed a month end, and you have data with service dates in 2011. Centricity Users: Data will not show until you have completed a system close in 2011 AND your nightly update has run and reports refreshed. Medicare Fee Schedule Update for 2010 (Revenue Recovery / Payment Audit Users CMS made changes to the Medicare Fee Schedule, that affect the first part of 2010 Medicare's fee schedule. Due to this, you will need to make changes to your Medicare Fee Schedules that are effective January 1 - May 31, 2010. Medicare now has two sets of fee schedules for 2010. To assure that your DataPlus system is using the correct 2010 Fee Schedules, follow these steps: Navigate to your Medicare Contract that is effective January 1 and ends May 31 2010 (you should have a separate set of contracts for June 1 - December 31 2010). Click Delete and Re-Add Fee Schedule Type YES to confirm deletion. When prompted, select Create Medicare Fee Schedule, and select the appropriate Medicare carrier. Click Add Codes and Continue. If your practice utilizes fee schedules for Facility, Non Facility and ASC payment types, then this procedure will need to be followed for each of those contracts. No changes need to be made to your second half of 2010 Medicare contracts. If you have commercial contracts that are based upon the Medicare 2010 Fee Schedules, you will need to delete and re-add those fee schedules as well. Once this procedure is complete, the Payment Audit System will automatically recalculate the appropriate allowed amounts and either move in, or move out underpayments based upon the new information. This happens during the month end process for HealthPort users, and during the nightly process for Centricity users. As always, should you have any questions, or need any assistance, please contact our support representatives by phone, email, or direct connect via our website. Sincerely, The DataPlus Support Team

Eight Ways to Start a Performance Evaluation

by Mary Pat Whaley http://www.managemypractice.com/ Many managers find it difficult to begin performance evaluations in a way that puts the employee at ease and opens the door to dialogue. Do you make small talk or start reading from whatever form you’re using? Do you preface the actual evaluation by setting the mood giving visual or tonal clues that it’s going to be a good evaluation or a bad evaluation? Here are eight ways to start a performance evaluation and get things started on the right foot: Review the agenda for the performance evaluation. This is especially important if you’re new to the organization and the employees are not sure what to expect. Tell the employee what information you’ll review and encourage them to ask questions so it’s an interactive evaluation, not just you telling them your thoughts. Review the job description to see what changes, if any, need to be made based on duties added or removed during the year. Review last year’s evaluation. Amazingly, many managers don’t look back at last year’s evaluation. How can improvement or goals be assessed if you’re not making a measurement between last year and this year? Discuss big events at the group that impacted the staff. Providers coming or going. Installing EMR. The installation of other software. A move. Merging with other groups. Discuss it. Discuss the employee’s significant events in the past year. A baby? A marriage? A divorce? A move? A Family Medical Leave Act (FMLA) leave? A new position? Discuss it. Review the self-evaluation if you’ve asked the employee to complete one, and I hope you have. Read the employee’s answers aloud and ask questions about what they meant. Here’s my favorite simple self-evaluation. If the evaluation is related to a raise or bonus, start by telling them if you’re giving them a raise or a bonus. This is an unusual way to start an evaluation, but I’ve used it in the past if the employee is unable to relax and really participate in the evaluation because they’re so worried about the raise. By the way, it’s usually the really good employees who are worried – the so-so employees tend to expect the raise and don’t worry about it. Do not start an evaluation by telling an employee you are NOT giving them a raise or a bonus. Review continuing education that the employee completed and ask what they learned and how they implemented what they learned. All of these suggestions give the manager the opportunity to start the evaluation on a relaxed note and engage the employee in meaningful discussion. Note: I am excited to announce a new book from Manage My Practice coming in July 2011: “The Smart Manager’s Guide to Mastering Performance Evaluations.” Stay tuned for more details. Image provided by Wikipedia. Related posts: Dear Mary Pat: Should Staff Be Allowed to Use The Internet on Their Smart Phones at Work? I think so. But I know I’m probably in the... “How’s It Ben Going”: Caregiver Ben Makes Flip Camera Videos for Heartland Health and 15 Ways You Can Use Video in Your Practice If you’re wondering how to get your point across to... 10 Ways for Physician Practices to Comply With the 2011 OIG Work Plan Image by rileyroxx via Flickr The Office of the Inspector...

View article...