March Madness... Health Care Reimbursement is a Crazy Thing!
I just spent three days at a national conference in Baltimore, MD where all things Medicare and Medicaid were discussed. There is no way to give sufficient detail in a blog post to all that we discussed and all that there is to think about and attend to following this conference but, let me share just a few of the highlights...
The Anti-Markup rule continues to be on the minds of attorneys advising health care providers. If you work with physicians who bill globally for diagnostic tests that they order, the time is now to make sure that those diagnostic services are being billed appropriately by the physician. Particularly as it relates to the professional interpretations of those services, the options for physicians are very limited. More importantly, what was okay last year may not be now so just because it was an arrangement previously blessed, doesn't me that it still is ... time to check. On the technical component side, remember that the technical component of a diagnostic test is performed where the patient is AND where the supervising physician is while the test is being done. And, remember that if you don't get this right, you can be left without the ability to bill anything.
Lots of people paying attention to "patient status"... i.e. inpatient, outpatient and observation status. The coordination of medical staff and hospital bylaws, hospital policies, and physician documentation to get the patient slotted into the correct status seems to have many health care institutions and their attorneys on edge. Certain the RACs don't help with the stress here. Pay attention to Condition Code 44 for a patient that you are moving from inpatient to outpatient status. Apparently, there are a lot of hospitals and providers that may not realize that this change needs to be made BEFORE the patient leaves the hospital if you are going to bill the maximum amount.
Since I mentioned them, on the subject of RACs, it appears that the "good news" may be that providers will likely see coding audits start before the medical necessity audits. In addition, it appears that health care providers will get some notice as the RACs expand their medical necessity scope. CMS has indicated that before RACs can expand the scope of their medical necessity audits to review new "issues", they must get approval from CMS and CMS intends to post those new issues on its Web site if the RACs are granted authority to audit those issues. On the less good news side of things, physicians should expect to get a fair amount of attention in this round of RAC audits. CMS has indicated that the RACs will be doing crossover audits of physicians when they find hospital admissions that seem to raise concern. Condition Code 44 came up in this discussion as well. Clearly there is a sense that hospitals have not been handling the use of this code correctly. Finally, CMS has indicated that RACs will have authority to review the use of "present on admission" codes as part of their coding reviews.
But, as usually, the most interesting discussions, at least for me, focused on Stark and the latest word on the DFRR. The conference began with the buzz about the OIG Open Letter indicating that the voluntary disclosure protocol is no longer available for the disclosure of violations that involve only the Stark law and not the Anti-Kickback statute. There was much debate about whether this new OIG position suggest that the OIG is overwhelmed by disclosures of potential Stark violations (suggesting that perhaps its too easy for a health care provider to find itself cross ways with Stark) or whether it suggests that OIG intends to more aggressively go after Stark violations and no longer wants providers to seek the safe haven of the voluntary disclosure protocol to take away their opportunity. I will admit that I tend to be more of a skeptic as to OIG's intentions the more that I think about the DFRR.
The latest word on the DFRR is still that no one knows for sure if or when hospitals that are going to get the DFRR questionnaire will get it. The expectation is that of the 400 that may go out, approximately 290 of those will go to all of the hospitals that got the original voluntary survey request in 2006 and failed to respond. That means that if you were not one of those hospitals, your chances are slim that you will get a questionnaire ... at least in this first round. Still, if you don't feel particularly lucky or just want to continue to move forward in getting a handle on some of your Stark compliance stuff, here are some good suggestions that came out of these discussions:
- query your accounts payable, check ledgers, and accounts receivable department for a list of ALL financial arrangements involving a physician;
- look for all leases for equipment and space that involve physicians;
- get a complete handle on your non-monetary compensation tracking and your medical staff incidental benefits;
- gather all of the documentation you can find for all of these;
- check them all for compliance with at least one Stark exception;
- for any possible non-compliance, determine whether you are in a "period of disallowance"; and
- before you even think of responding to a DFRR request, if you get one, check with legal counsel. Because of the details of the questionnaire, how you respond is very important.
Obviously, this is just a small window into what was three solid days of all that is Medicare. There is certainly more to come on this topic, particularly given that the season of CMS proposed payment rule is just about to begin.
