Prior authorizations will ease pressure, CMS says

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Friday, February 24, 2012

WASHINGTON - CMS answered a few key questions about the PMD demonstration project during a Special Open Door Forum last week. Among the most important: Will the required prior authorizations help protect providers against post-payment reviews?

CMS officials said they should, at least with MAC and RAC audits on medical necessity and other elements included in the prior authorizations.

But "there could be other requirements that are not reviewed during the prior authorization process, like the home assessment," said Melanie Combs-Dyer, deputy director of the Provider Compliance Group at CMS.

Also, providers may still be subject to CERT audits and fraud-fighting audits like ZPICs, CMS officials said.

Still, the audits that do take place should be easier on providers, Dyer said.

"Hopefully that would be a much shorter review--you've got that on file and it's nothing you'd have to write to the physician and track down," she said. "We really do believe that having in place this prior authorization process will make life easier for suppliers in terms of post-payment reviews." 

Last week's forum was the first opportunity that providers had to get more information about the revamped seven-state PMD demo since CMS announced Feb. 3 that it would drop the prepay review phase. The demo is set to begin on or after June 1.

Other new information: Prior authorization decisions will be sent to providers, physicians and patients within 10 business days. If denied, the decisions will come back with detailed explanations. The number of allowed resubmissions is unlimited, with 30-day response times from the DME MAC.

Several aspects of the process will remain the same: The agency will still allow a 48-hour expedited review of prior authorizations for emergency cases; providers who do not want to go through prior authorizations may choose not to, but will take a 25% reimbursement cut (after a three-month grace period); and physicians will still be able to bill for time spent preparing prior authorizations (providers may submit that paperwork on the physician's behalf, without the extra compensation).

CMS will continue to offer educational outreach in the coming months, including monthly Open Door Forums through July.

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Comments

Pay particular attention to the quotes from CMS employee, Melanie Combs-Dyer, with the words: <br />
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"there could be other requirements that are not reviewed during the prior authorization process, like the home assessment," and <br />
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"Hopefully that would be a much shorter review--you&#39;ve got that on file and it&#39;s nothing you&#39;d have to write to the physician and track down,"<br />
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Until some definitive parameters are established governed by some agency preferably the Courts; the entire industry is running on hopefully, should and could with CMS!

I am as cautious with the motives of CMS as anyone, but this doesn&#39;t worry me. These Udits will focus on delivery paperwork and home assessments.

Frank; read the two articles I pasted below then continue down. It seems CMS has different AUDIT criteria and different classifications for certain people with the same actions.<br />
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Article 1:<br />
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WASHINGTON - Healthcare fraud prevention and enforcement efforts recovered nearly $4.1 billion in taxpayer dollars in fiscal year 2011, according to a new report. The report, from the Health Care Fraud and Abuse Control Program (HCFAC), was released last week by the U.S. Departments of Justice, and Health and Human Services.<br />
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"This report reflects unprecedented successes by the departments in aggressively preventing and combating healthcare fraud, safeguarding previous taxpayer dollars and ensuring the strength of our essential healthcare programs," stated Attorney General Eric Holder in a release.<br />
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The departments credit President Obama, who has made eliminating fraud, waste and abuse a top priority in his administration; the Health Care Fraud Prevention & Enforcement Action Team (HEAT), which was created in 2009 to prevent fraud in the Medicare and Medicaid programs; and the Medicare Fraud Strike Force.<br />
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In 2011, strike force operations resulted in charging a record number of 323 defendants, who allegedly collectively billed Medicare more than $1 billion. They also resulted in 172 guilty pleas, 26 convictions and 175 prison sentences. The average prison sentence in these cases was more than 47 months. Including these operations, federal prosecutors filed criminal charges against 1,430 defendants for healthcare fraud-related crimes, the highest number in a single year in the DOJ&#39;s history.<br />
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The recently enacted Affordable Care Act provides additional tools and resources to help fight fraud, including an additional $35 million for HCFAC<br />
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Article 2:<br />
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Feds to curb improper payments to Medicare plans<br />
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Feb 24, 4:42 PM (ET)<br />
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Associated Press <br />
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WASHINGTON (AP) - The Obama administration says it&#39;s taking steps to fix a longstanding problem of improper payments to private health plans that serve 1 in 4 Medicare beneficiaries. So-called Medicare Advantage plans face tighter audits under a policy issued Friday. The rules say Medicare must pay the plans a higher rate to care for sicker beneficiaries. But previous government audits discovered many claims were not backed up by proper medical documentation. Medicare deputy administrator Jon Blum says he doesn&#39;t call it fraud, but it is a problem. The estimated error rate of 11 percent added up to $12 billion in improper payments last year. <br />
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The Obama administration says it wants to gradually reduce erroneous payments while maintaining quality. Medicare expects to save $370 million beginning this year, and more over time.<br />
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How Serious Is Washington and AG Eric Holder?:<br />
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Big Insurance Companies with deep pockets overpaid is a problem. The healthcare Provider overpaid is Fraud! The statistics contained in these two articles states the Obama Task Force spent millions in taxpayer dollars and collected $4.1 billion from overpaid providers. Insurance Companies were overpaid a little less than 3x the $4.1 billion collected from overpaid healthcare Provders $12 billion. What was spent to collect from them zero!!! The Obama administration says it wants to gradually reduce erroneous payments while maintaining quality. <br />
Medicare expects to save $370 million beginning this year, and more over time. Operative word "gradually". The $12 billion minus $370 million it expects to save this year leaves $11.63 billion overpaid to Insurance Companies this year!!! Therefore, if you are an Insurance Company overbilling Medicare without "proper medical documentation" you are considered only a problem. A provider billing medicare without proper medical documentation is prosecuted as a "criminal". Why? Shouldn&#39;t everyone be prosecuted the same way for the same actions? You may want to pass this around!<br />
Great use of taxpayer dollars. <br />
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Now does everyone understand why medicare has a problem?<br />
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Now you know the rules!<br />