CACS, MACS & RACS – WHAT TO EXPECT IN 2009 - GASCO · 2008-12-03 · CACs/MACs/RACs – Dec 2008...

1CACs/MACs/RACs – Dec 2008

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CACS, MACS & RACS CACS, MACS & RACS ––WHAT TO EXPECT IN 2009WHAT TO EXPECT IN 2009

Presented to GASCO University December 3, 2008


Presented by:Presented by:

Karen BeardKaren BeardDirector Director

Georgia Society of Clinical Oncology


Medicare Carrier Advisory Committee Medicare Carrier Advisory Committee (CAC)(CAC)

• Georgia’s Part B Carrier is CAHABA GBA.• The region covered by CAHABA has included

Alabama, Georgia and Mississippi• Until early 2005, all three states had 3 separate

Medical Directors and three sets of Local Carrier Determinations affecting oncology.

• Medicare law requires a CAC for each state, but only 1 medical director per jurisdiction


GASCO’sGASCO’s Relationship Relationship with The Georgia CACwith The Georgia CAC

• Meetings are at least 3 times per year in Atlanta• During that time GASCO can:

• discuss comments to draft LCDs; • request revisions to existing LCDs; • and bring additional oncology specialists to provide comments or

scientific data on oncology related topics. • Provide information on early release of trial results• Answer MD questions on off label use appeals • Note: Local Carriers cannot make any coverage decision

exceptions or modifications to a National Carrier Decision (NDC)


GASCO’sGASCO’s Relationship with Relationship with The Georgia CACThe Georgia CAC

• GASCO Provides 2 representatives and alternates to the CAC for hematology, oncology and a special advisor for radiation oncology

• Due to the rapid changes in cancer related diagnostic and therapeutic medicine, GASCO has maintained a relationship with the Part B Medical Director.

• This role now being handled by 1 Medical Director - Dr. Greg McKinney - His AA, Kathy Thomas, can be reached at 205/220-1215. - email is [email protected]


Changes in the LCD Approval ProcessChanges in the LCD Approval Process• In 2005 CAHABA replaced individual state LCDs with

consolidated LCDs applicable to all 3 states

• The policy gains previously won by GASCO had to be revisited for over 25 oncology policies & additional polices with oncology diagnosis codes

• e.g. – New consolidated policy for Complete Metabolic Panel left off a large number of cancer ICD codes contained on previous policies.


Preparation for CAC MeetingPreparation for CAC MeetingGASCO obtains the draft LCDs usually a month before the CAC meeting for all draft LCDs to see if hem/ onc is affected.

GASCO’s ChairmanDirector analyzes changes from previous LCDs and distributes the drafts to GASCO’s Clinical Practice Committee (MDs, Nurses, Pharmacists, Administrators)

Copies are sent to the CAC members for Mississippi and Alabama.

GASCO collects comments from all three states – and sets a conference call for all 3 states to discuss any differences in advance of the State CAC meetings


ResultsResults• Presents a more consistent and organized method

of addressing policy issues• High level of trust between GASCO & Carrier

Medical Director • Direct contacts for Medicare policy staff often

with same day responses on issues• Creates a model for cooperation during future

CMS consolidation


LCD Retirements LCD Retirements

• Contractors will retire when data show not as important – does not mean LCD is “incorrect”

• Responsibility for correct performance, coding, billing and medical necessity under Medicare, remains with provider offices

• Responsibility for correct claims submission is unchanged whether or not an LCD is in place


CMS Part A&B ConsolidationsCMS Part A&B Consolidations

• Important to reach out to other Societies in new MAC regions for consensus on LCD recommendations during consolidation

• So far the LCD accepted for most jurisdictions has been the least restrictive – This can change based on bid winner’s philosophy

2

1

2

1

4

3

5

7

9

10

15

8

6

11

14

13

12

New A/B MAC Jurisdictions

3

N

N

= Start-up

= Cycle One

= Cycle Two


Medicare Contracting ReformMedicare Contracting Reform

1/2005 1/2006 1/2007 1/2008 1/2009 1/2010

MAC Procurement MAC Transitions

RFP (3/05) Award (12/05) Cutover (7/06)


4 DME MACs – On Hold1 A/B MAC “Start-Up” = “J3”

7 A/B MACs “Cycle One”

7 A/B MACs“Cycle Two”

4 HH MACs



Start-upCycle

CycleOne

CycleTwo

↑


Medicare Contracting ReformMedicare Contracting ReformWhere A/B MAC contract awards stand now:

• Jurisdiction 3 (“J3”) to Noridian in 2006• J4 awarded to TrailBlazer Health Enterprises • J5 awarded to Wisconsin Physician Service (WPS)• J1 to Palmetto GBA- Protested; resolved for Palmetto• J12 to Highmark – Protested; resolved for Highmark• J13 to National Government Services (NGS)• J2 to National Heritage Insurance Corp (NHIC)• J7 to Pinnacle Business Solutions, Inc. (PBSI)• J9 to First Coast Service Options• J14 to National Heritage Insurance Corp (NHIC) – 11/18GA/TN/AL – J10 – Due by 10/08 - Delayed Remaining 4 A/B MACs to be awarded thru 2009DME MAC awards have been pit on hold

www.cms.hhs.gov/medicarereform/contractingreform

Medicare FeeMedicare Fee--ForFor--Service ProgramService ProgramAdministrative Functional EnvironmentAdministrative Functional Environment


Recovery Audit Contractors (RACs)

• Improper Payment Information Act requires federal agencies to measure and reduce improper payment rates

• “Improper payments” include• overpayments • underpayments


Office of Management & Budget (OMB) Office of Management & Budget (OMB) 8 Agencies = 88% of overpayments8 Agencies = 88% of overpayments

$12.9 BMedicaid

$11.4 BEarned Income

Tax Credit$10.8 BMedicare

$6.7 BOther

$4.1 BSupplemental Security

Income

$2.5 BOld Age Survivors' Insurance

Unemployment Insurance

$1.8 BFood Stamp Program

$1.4 BNational School Lunch Program

Medicare receives over 1.2 billion claims per year.

This equates to:4.5 million claims per work day574,000 claims per hour9,579 claims per minute


RAC LegislationRAC Legislation

• Medicare Modernization Act, Section 306: required RAC demonstration

• Demonstration – March 2005 – March 27, 2008

• Tax Relief and Health Care Act of 2006, Section 302: requires permanent and nationwide RAC program no later than 1/1/2010

TEMPORARILY ON HOLD DUE TO CHALLENGES


Recovery Audit Contractors (RACs)

• CMS pays each RAC on a contingency fee basis; i.e. a percentage of what the RACs identify and collect from providers.

• 1st time the Medicare program has ever paid a contractor on a contingency fee basis for claim review and overpayment collection work!


RAC Administrator Awards & FeesRAC Administrator Awards & Fees

• Connolly Consulting (Connolly) – (Georgia’s administrator) – 9%

• Health Data Insights (HDI) – 9.49%• Diversified Collection Services, Inc. (DCS)

- 12.45% • CGI Technologies – 12.5%


RAC contract includes the following tasksRAC contract includes the following tasks

1. Identifying Medicare claims that contain non-MSP underpayments for which payment was made under part A or B.

2. Identifying and Recouping claims that contain non-MSP overpayments for which payment was made under part A or B. Includes corresponding with the provider.


RAC Tasks RAC Tasks -- continuedcontinued

3. For any RAC-identified overpayment that is appealed by the provider, the RAC shall provide support to CMS throughout the administrative appeals process and, where applicable, a subsequent appeal to the appropriate Federal court.

4. For any RAC-identified vulnerability, support CMS in developing an Improper Payment Prevention Plan to help prevent similar overpayments from occurring in the future.


RAC Tasks RAC Tasks -- continuedcontinued5. Performing the necessary provider outreach to notify

provider communities of the RAC’s purpose and direction.

NOTE: The proactive education of providers about Medicare coverage and coding rules is NOT a task under RAC statement of work. CMS has tasked QIOs, FIs, Carriers, and MACs with the task of proactively educating providers about how to avoid submitting a claim containing a request for an improper payment.


How RACs Select ClaimsHow RACs Select Claims

• Choose areas of focus based on data mining techniques, OIG & GAO reports, CERT reports & experience and knowledge of staff

• Two types of review (depending on certainty)• Automated (no medical record) – Certainty• Complex (medical records reviewed within 60 days)- No

certainty

• New Issues for review will be posted to RACs website


RAC Review ProcessRAC Review Process

• Use same Medicare policies as FIs, Carriers and MACs: NCDs, LCDs & CMS manuals

• Use same types of staff as FIs, Carriers and MACs: nurses, therapists, certified coders & physician CMD


Summary of Medical Record Limits Summary of Medical Record Limits (for FY 2009)(for FY 2009)

• Inpatient Hospital, IRF, SNF, Hospice • 10% of avg mthly Medicare claims (max of 200) per 45 days

• Other Part A Billers (Outpatient Hospital, HH) • 1% of average monthly Medicare services (max of 200) per 45

days

• • Physicians • Solo Practitioner: 10 medical records per 45 days • Partnership of 2-5 individuals: 20 medical records per 45 days • Group of 6-15 individuals: 30 medical records per 45 days • Large Group (16+ individuals): 50 medical records per 45 days


Assuring Accurate DecisionsAssuring Accurate Decisions

• New Issue Review• CMS will review all new issues proposed for review by the RAC

• Validation Process• Validation Contractor will review a random sample of each RACs

completed reviews• CMS will release an accuracy score for each RAC on an annual basis

• Appeal Process• If RAC loses on any level of appeal, RAC pays back

contingency fee


Medicare Payments Affected by RACs - Cumulative through 9/30/07

$436.1 m

Medicare PaymentsFound by the RACs to be Improper

0.2%

$239.2 b

Medicare PaymentsUnaffected by RACs

99.8%


FY 07 FindingsFY 07 Findings

Overpmts Collected: $357.2 mLess Underpmts Repaid: - ($14.3 m)

Less $ Overturned on Appeal: - ($17.8 m)Less Costs to Run Demo: - ($77.7 m)

BACK TO TRUST FUNDS $247.4 m


FY 07 FindingsFY 07 FindingsOverpayments Collected by Provider TypeOverpayments Collected by Provider Type

• Most overpayments were collected from inpatient hospitals

SOURCE: RAC Data Warehouse

2%

88%

6%

3%1%

DME Supplier $5.5m

Inpatient Hosp/SNF

Outpatient Hosp $22.6m

Physician $12.2mAmb, Lab, Oth $4.1m

$312.8m

31CACs/MACs/RACs – Dec 2008 31

FY 07 Overpayments Collected FY 07 Overpayments Collected by Error Typeby Error Type

(Net of Appeals)(Net of Appeals)

• Most improper payments occur when providers submit claims that don’t comply with Medicare coding rules or medical necessity guidelines

SOURCE: Self-reported by RACs

17%Other

9% No/Insufficient Documentation

32%Medically

Unnecessary Service or Setting

42%Incorrectly Coded

RAC Findings Similar to CERT Findings

CERT found that:

•25.6% of the error rate was due to No/Insufficient Documentation errors

• 33.3% of the error rate was due to Medically Unnecessary errors

•38.4% of the error rate was due to Incorrect Coding errors

•5.1% of the error rate was due to Other errors

Top Services with RACTop Services with RAC--Initiated Overpayment Collections Initiated Overpayment Collections Claim RACs OnlyClaim RACs Only

NY

NY, FL, CA

FL

NY, FL, CA

NY, FL, CA

Surgical procedures in wrong setting (medicallyunnecessary)

Excisional debridement (incorrectly coded)

Cardiac defibrillator implant in wrong setting (medicallyunnecessary)

Treatment for heart failureand shock in wrong setting(medically unnecessary)

Respiratory systemdiagnoses with ventilatorsupport (incorrectly coded)

Inpatient Hospital

Location of ProblemDescription of Item or ServiceType of Provider


CA

CA

Physical therapy and occupational therapy (medically unnecessary)

Speech-language pathology services (medically unnecessary)

Skilled Nursing Facility

NY, FL

NY, CA

CA

Neulasta (medically unnecessary)

Speech-language pathology(medically unnecessary)

Infusion services

Outpatient Hospital

CA

CA

Services following joint replacement surgery (medically unnecessary)

Services for miscellaneous conditions (medically unnecessary)

Inpatient Rehabilitation Facility

Location of ProblemDescription of Item or ServiceType of Provider


NY, FL, CAItems during a hospital inpatient stay or SNF stay (other error type)

Durable Medical Equipment

FL, CAAmbulance service during hospital Inpt stay

Lab/Ambulance/Other

NY, CA

NY

FL

CA

Pharmaceutical injectables (incorrect coding, wrong units)

Neulasta (medically unnecessary)

Vestibular function testing (other error type)

Duplicate claims (other error type)

Physician

Location of ProblemDescription of Item of ServiceType of Provider

National Expansion ScheduleNational Expansion Schedule

D

C

B

A

Summer 2008

Fall 2008

Jan 2009 or later

All dates are flexible

Names of new RACs will be announced in: TBD


RAC ExpansionRAC Expansion• To All MAC Areas by 1/01/2010• Look-Back to be three years• “Oldest” look-back to be 10/1/ 2007• No RAC review of claims previously in appeal

or complex review such as by Carrier, MAC, PSC, CERT

• Six month “blackout period” from 3 months before a MAC transition until 3 months after


Medicare Enrollment Changes 1/1/2009Medicare Enrollment Changes 1/1/2009PLAN AHEAD FOR NEW ASSOCIATES & BUY-INS• CMS has re-defined the effective date of billing for

physicians & NPPs as the later of these two dates –(1) the date of filing of a Medicare enrollment application that was

subsequently approved by a Medicare contractor versus (2) the date an enrolled physician or non-physician practitioner first

started furnishing services at a new practice location.

• Approved apps for Physicians and NPP may only bill retrospectively for services furnished up to 30 days prior to the effective date instead of the 23 months allowed under current regulations.


Medicare Enrollment Changes 1/1/2009Medicare Enrollment Changes 1/1/2009

The rule requires physicians & NPPs to report any changes of ownership, adverse legal actions, or change in practice location within 30 days (versus the current 90 days) or face revocation of Medicare billing privileges and the recoupment of Medicare payments from the date of the reportable change.


For more information contact:

• Karen Beard – Director/GASCO3330 Cumberland Blvd, Suite 200Atlanta, GA 30339

• Toll Free (877) 88GASCO • Fax: (770) 951-2157 • e-mail: [email protected]

CACS, MACS & RACS – WHAT TO EXPECT IN 2009 - GASCO · 2008-12-03 · CACs/MACs/RACs – Dec 2008...

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Transcript of CACS, MACS & RACS – WHAT TO EXPECT IN 2009 - GASCO · 2008-12-03 · CACs/MACs/RACs – Dec 2008...