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Oh Canada.


quote: In 2012 CMS will perform an audit before paying for several big ticket cardiology and orthopedic procedures in certain key states. The news has provoked strong reactions from cardiologists and Wall Street.

In Florida, in fact, 100% of stent, ICD, and pacemaker implantation procedures will undergo review before payment. Similar programs will take place in California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri, but the precise percentage and mix of cases that will undergo auditing has not yet been stated.

Forbes
 

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After years of criticism that it has paid billions of dollars for unnecessary procedures, the Centers for Medicare & Medicaid Services (CMS) will soon ramp up efforts to rein in costs for unnecessary procedures. In 2012 CMS will perform an audit before paying for several big ticket cardiology and orthopedic procedures in certain key states. The news has provoked strong reactions from cardiologists and Wall Street.

In Florida, in fact, 100% of stent, ICD, and pacemaker implantation procedures will undergo review before payment. Similar programs will take place in California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri, but the precise percentage and mix of cases that will undergo auditing has not yet been stated.

On November 15 the demonstration program was announced by CMS:

The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they have been made.

On November 21 Juan Aranda, Jr, the president of the Florida chapter of the American College of Cardiology (ACC), sent a letter to all ACC members in Florida about the “very serious proposed changes… that you need to be aware of immediately.” Arunda said that the Florida ACC “is fighting these onerous regulations” and that staff at the national ACC headquarters planned to meet with CMS officials.

Details of the CMS initiative only became widely known on Friday, when Wells Fargo analyst Larry Biegelsen issued a report summarizing the initiative in which he cited “reimbursement experts who have all indicated that this initiative seems onerous for hospitals and will likely reduce procedure volume because hospitals will begin making sure that every patient meets the coverage criteria.”

Reaction to the report on Wall Street was immediate. According to an article in Bloomberg News, hospital and medical device stocks plunged after the report was issued on Friday. Tenet Healthcare dropped 11% while Medtronic lost 6%.

Here is the position of the Florida ACC chapter, as stated by Jerold Saef, the chair of the Third Party Reimbursement committee of the chapter, in the letter to Florida cardiologists:

As of the first of the year, there will be 100% pre-payment audits on all inpatient hospital stays relative to 15 DRG’s. 11 of these are cardiac and 4 are orthopedic. This means that all inpatient stays involving a listed DRG will trigger a hold on any payment associated with Part A reimbursement. Hospitals will not be paid for 100% of these admissions pending record review. There will be a 30-60 day period during which the hospital records will be reviewed for whether they support medical necessity for procedures which occurred during the stay. The Part B (physician) payment will proceed. If the determination is made that records do not support necessity, then the entire hospital stay will be denied. The physicians will receive a form letter which will be entitled a “Take-Back Letter” requiring return of any funds paid in conjunction with the affected hospitalization. This will affect all cardiologists and orthopedists involved in the care – both invasive and noninvasive. This may include outpatient reimbursement for follow-up care related to the hospitalization. It’s not clear whether other specialists or primary care physicians will also receive Take-Back Letters.

The premise under which this program is being initiated is that physicians are not adequately documenting the justification for their procedures and that as many as half the procedures performed may be unnecessary. This estimate apparently arises from White House and Congressional concerns that unnecessary procedures are being funded. They draw their conclusions from Comprehensive Error Rate Testing (CERT).

In our discussions with FCSO, we are told this is an instruction from The Center for Medicare and Medicaid Services (CMS), and that it is being implemented nationally. We have confirmed via the National ACC that this is the case in at least 10 other states. We are also told that if, after a matter of months, it appears that the scrutiny being used is unnecessary, there will be a shift in focus away from the initial DRG’s towards other, different DRG’s.

The Chapter leadership is concerned that the Pre-Payment Audit Initiative is being launched at all and, additionally, that it is being launched with little more than 6 weeks warning. The FCACC and the Florida Orthopedic Society both think that the previous Local Coverage Determinations (LCD) that were formulated should have provided FCSO with the necessary tools to fight over-utilization and fraud, and that no additional measures are necessary at this time. It occurs when holidays are imminent and end of the year finances are being addressed. We consider this unfair and unprecedented. We are concerned that cardiology practices, already subject to huge technical component cuts, loss of consult codes, increasing certification overhead, costs of implementation of electronic medical record systems and the Sustainable Growth Rate issue, will now be threatened by unjustified “Take-Back” strategies.

Here is the list of DRGs which will be subject to 100% prepayment medical review in Florida:

226 — Cardiac defibrillator implant without (w/o) cardiac catheter with (w/) major complications or comorbitities (MCC)
227 — Cardiac defibrillator implant w/o cardiac catheter w/o MCC
242 — Permanent cardiac pacemaker implant w/MCC
243 — Permanent cardiac pacemaker implant w/CC
244 — Permanent cardiac pacemaker implant w/CC or MCC
245 — Automatic implantable cardiac defibrillator (AICD) generator procedures
247 — Percutaneous cardiovascular procedure w/drug eluding stent w/o MCC
251 — Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC
253 — Other vascular procedures w/CC
264 — Other circulatory system or procedures
287 — Circulatory disorders except acute myocardial infarction (AMI), w/cardiac catheter w/o MCC
458 — Spinal fusion except cervical w/spinal curve, malign, or 9+ fusions w/o CC
460 — Spinal fusion except cervical w/o MCC
470 — Major joint replacement or reattachment of lower extremity w/o MCC
490 — Back and neck procedures except spinal fusion w/CC/MCC or disc device/neurostimulator



or are you suggesting muffin that people be allowed to continue to waste your scarce government resources?
 

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Discussion Starter #4
...

or are you suggesting muffin that people be allowed to continue to waste your scarce government resources?
By all means, catch the crooks abusing the system,
but let doctors, not government bean counters, practice medicine.
 

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Money is tight right now, in case anyone hasn't noticed. Cutting the deficit means stopping waste. In the absence of hard facts on criteria for denying payment and evidence of existing fraud, we can't really know if this is a heartless measure or common sense.

BTW: This sort of auditing and justification of procedures is already being done in private health care plans.
 

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Discussion Starter #9
so, doctors are above auditing and dishonesty?
Do you even read what you copied ?
The purpose of the directive is to rein in costs for "unnecessary procedures".

In this context, deciding what is necessary or not is the practice of medicine.
 

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And you think private insurance companies don't do that?
 

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LOL

Obamacare is now picking up the best practices from the health care insurance industry.
Since when is Medicare and Medicaid "Obamacare"?
 

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Discussion Starter #15
What a savings !!
For a whopping $2B, I bet they could hire 1000 more guv auditors.

quote:As a means to thwart improper payments and reduce payment errors, the Centers for Medicare & Medicaid Services (CMS) put forth three new projects for 2012

designed to cut the Medicare fee-for-service error rate in half and recover nearly $2 billion in improper payments.

According to CMS, an additional goal of the projects is to reduce overall payment errors by $50 billion.

To achieve these goals, CMS announced in November that will launch three demonstration projects beginning January 2012 to help curb improper payments by pinpointing the most common factors that cause fraud, waste and abuse:

* Recovery Audit Prepayment Review: The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. According to CMS, the RACs will conduct reviews on claims led to high rates of improper payments in the past. The reviews will focus on seven states: Florida, California, Michigan, Texas, New York, Louisiana and Illinois. CMS’ goal is to reduce the error rates by preventing improper payments before they are made.

* Prior Authorization for Certain Medical Equipment: This project will require prior authorization for certain medical equipment and devices, including cardiac devices and cardiovascular-related procedures, for Medicare beneficiaries who live in seven states that have had high rates of fraud and error: California, Florida, Illinois, Michigan, New York, North Carolina and Texas. This will aim to appropriately bill and prevent errors in payments.
* Part A to Part B Rebilling: The third initiative will allow hospitals to rebill for 90 percent of the Part B payment when a Medicare contractor denies a Part A inpatient short stay claim as not reasonable and necessary due to the hospital billing for the wrong setting. Currently, when outpatient services are billed as inpatient services, the entire claim is denied in full.

According to CMS, the prior authorization requirement will be implemented in two phases of the three-year project. During the first phase, during the first three to nine months, Medicare administrative contracts will conduct reviews on certain medical equipment claims. In the second phase, prior authorization will be implemented as a tool used by private-sector healthcare payors to prevent improper payments and curb fraudulent payments.

As far as Part A to Part B Rebilling project goes, hospitals will be allowed to resubmit claims for 90 percent of the allowable Part B payments if a medicare administrative contractor or recovery auditor find that a beneficiary met the requirements for Part B services but not Part A inpatient stay requirements.

According to CMS, the improper payment rate for Medicaid is 8.1 percent ($21.9 billion); however, this rate decreased 1.3 percent when the U.S. Department of Health and Human Services (HHS) stepped in to educate providers on the causes of most improper payments.

“While improper payment rates are not necessarily an indicator of fraud in Medicare, Medicaid, they do provide HHS, CMS and states with a more complete assessment of factors leading to error rates and new ways to help prevent them,” CMS summed in a statement. “CMS is continuing to invest time and resources to work with providers across the country and eliminate errors through increased and improved training, education, and outreach.”
 

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lmftfu

After years of criticism that it has paid billions of dollars for unnecessary procedures, the Centers for Medicare & Medicaid Services (CMS) will soon ramp up efforts to rein in costs for unnecessary procedures. In 2012 CMS will perform an audit before paying for several big ticket cardiology and orthopedic procedures in certain key states. The news has provoked strong reactions from cardiologists and Wall Street.

In Florida, in fact, 100% of stent, ICD, and pacemaker implantation procedures will undergo review before payment. Similar programs will take place in California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri, but the precise percentage and mix of cases that will undergo auditing has not yet been stated.

On November 15 the demonstration program was announced by CMS:

The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they have been made.

On November 21 Juan Aranda, Jr, the president of the Florida chapter of the American College of Cardiology (ACC), sent a letter to all ACC members in Florida about the “very serious proposed changes… that you need to be aware of immediately.” Arunda said that the Florida ACC “is fighting these onerous regulations” and that staff at the national ACC headquarters planned to meet with CMS officials.

Details of the CMS initiative only became widely known on Friday, when Wells Fargo analyst Larry Biegelsen issued a report summarizing the initiative in which he cited “reimbursement experts who have all indicated that this initiative seems onerous for hospitals and will likely reduce procedure volume because hospitals will begin making sure that every patient meets the coverage criteria.”

Reaction to the report on Wall Street was immediate. According to an article in Bloomberg News, hospital and medical device stocks plunged after the report was issued on Friday. Tenet Healthcare dropped 11% while Medtronic lost 6%.

Here is the position of the Florida ACC chapter, as stated by Jerold Saef, the chair of the Third Party Reimbursement committee of the chapter, in the letter to Florida cardiologists:

As of the first of the year, there will be 100% pre-payment audits on all inpatient hospital stays relative to 15 DRG’s. 11 of these are cardiac and 4 are orthopedic. This means that all inpatient stays involving a listed DRG will trigger a hold on any payment associated with Part A reimbursement. Hospitals will not be paid for 100% of these admissions pending record review. There will be a 30-60 day period during which the hospital records will be reviewed for whether they support medical necessity for procedures which occurred during the stay. The Part B (physician) payment will proceed. If the determination is made that records do not support necessity, then the entire hospital stay will be denied. The physicians will receive a form letter which will be entitled a “Take-Back Letter” requiring return of any funds paid in conjunction with the affected hospitalization. This will affect all cardiologists and orthopedists involved in the care – both invasive and noninvasive. This may include outpatient reimbursement for follow-up care related to the hospitalization. It’s not clear whether other specialists or primary care physicians will also receive Take-Back Letters.

The premise under which this program is being initiated is that physicians are not adequately documenting the justification for their procedures and that as many as half the procedures performed may be unnecessary. This estimate apparently arises from White House and Congressional concerns that unnecessary procedures are being funded. They draw their conclusions from Comprehensive Error Rate Testing (CERT).

In our discussions with FCSO, we are told this is an instruction from The Center for Medicare and Medicaid Services (CMS), and that it is being implemented nationally. We have confirmed via the National ACC that this is the case in at least 10 other states. We are also told that if, after a matter of months, it appears that the scrutiny being used is unnecessary, there will be a shift in focus away from the initial DRG’s towards other, different DRG’s.

The Chapter leadership is concerned that the Pre-Payment Audit Initiative is being launched at all and, additionally, that it is being launched with little more than 6 weeks warning. The FCACC and the Florida Orthopedic Society both think that the previous Local Coverage Determinations (LCD) that were formulated should have provided FCSO with the necessary tools to fight over-utilization and fraud, and that no additional measures are necessary at this time. It occurs when holidays are imminent and end of the year finances are being addressed. We consider this unfair and unprecedented. We are concerned that cardiology practices, already subject to huge technical component cuts, loss of consult codes, increasing certification overhead, costs of implementation of electronic medical record systems and the Sustainable Growth Rate issue, will now be threatened by unjustified “Take-Back” strategies.

Here is the list of DRGs which will be subject to 100% prepayment medical review in Florida:

226 — Cardiac defibrillator implant without (w/o) cardiac catheter with (w/) major complications or comorbitities (MCC)
227 — Cardiac defibrillator implant w/o cardiac catheter w/o MCC
242 — Permanent cardiac pacemaker implant w/MCC
243 — Permanent cardiac pacemaker implant w/CC
244 — Permanent cardiac pacemaker implant w/CC or MCC
040 -- black on black
245 — Automatic implantable cardiac defibrillator (AICD) generator procedures
247 — Percutaneous cardiovascular procedure w/drug eluding stent w/o MCC
251 — Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC
253 — Other vascular procedures w/CC
264 — Other circulatory system or procedures
287 — Circulatory disorders except acute myocardial infarction (AMI), w/cardiac catheter w/o MCC
458 — Spinal fusion except cervical w/spinal curve, malign, or 9+ fusions w/o CC
460 — Spinal fusion except cervical w/o MCC
470 — Major joint replacement or reattachment of lower extremity w/o MCC
490 — Back and neck procedures except spinal fusion w/CC/MCC or disc device/neurostimulator



or are you suggesting muffin that people be allowed to continue to waste your scarce government resources?

:D.
 

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I have been reading about this for years. In California’s more rural communities that are dominated by one hospital, can have wild differences in cardio care. Two areas with the same demographics can vary as much as 400% in Medicare/Medicaid supplied cardio procedures.
 

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Discussion Starter #19
As I said in my previous post, the $2B "saved" should pay for a fair number of guv contractors and the consulting companies.

quote: RECOVERY AUDIT PROGRAM PREPAYMENT REVIEW
Contingency fees ... and administrative costs will be paid out of funds that CMS saves by denying improperly billed claims.
 

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Discussion Starter #20
who are you trying to blame, FDR?
The insurance companies.

quote:
Key bit: Obama said of rationing care:

"Right now, insurance companies are rationing care. They are basically telling you what's covered and what's not. They're telling you, 'We'll cover this drug but we won't cover that drug. You can have this procedure or you can't have that procedure. So why is it that people would prefer having insurance companies make those decisions
rather than medical experts and doctors figuring out, you know, what are good deals for care and providing that information to you as a consumer and your doctor so you can make good decisions?"

 
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