Consumer-Driven Health Plans – What Should You Consider When Choosing?

Posted on May 15, 2012 by Linda Ringquist

According to the Bureau of Labor Statistics, the combination of a pretax payment account with a high-deductible health plan is what is commonly referred to as a consumer-driven health plan (CDHP).⁷ In terms of payment methods, CDHPs are composed of a three tier payment system

A savings account
BHM Healthcare Solutions
Out-of-pocket payments
Insurance plan.

The first tier is a pretax account that allows employees to pay for services using pretax dollars. The account may be funded by the employer or the employee, depending on the type of account. The funds from this account can be used to satisfy the insurance plan deductible. The second tier is the difference, or the “coverage gap,” between the amount of money in the individual’s pretax account and the deductible. The amount that is not covered by the pretax account must be covered by the insured. If health care expenses exceed the deductible amount, then the third tier, the high-deductible health insurance plan, kicks in.

In an article from the URAC website, there are ten things to be considered when evaluating and choosing consumer-driven health plans and products.

Is the information regarding the consumer health driven plan available in a variety of formats and media? Is the information available in different languages as applicable? Is the information written in such a way that it can be understood easily, including to those who may have mental or physical impairments or disabilities?
Are all of the costs laid out in a manner in which deductibles, out-of pocket expenses, tax consequences and benefits are clear?
Does the information indicate clearly the details of the plan, including benefits and coverage, customer satisfaction results, and a directory of providers?
Is wellness and prevention data readily available and easily accessible?
Do you have access to a Health Risk Assessment which is evidence-based, reviewed by the organization’s top clinical staff, and provide feedback as to the health status and any recommendations to improve the current health status?
Does the plan provide data explaining the enrollees role and responsibility for making their own decisions for health care? Are there additional expert resources available to the enrollee to help answer any additional questions.
Are there specific instructions as to how to access assistance on a 24/7 basis through different media such as phone, email, and in person?
Is there a method for requesting a detail of the cost and quality for each provider?
Does the health plan provide assistance in making financial decisions about coverage gaps, managed care or review processes necessary for coverage and how to seek care once the personal health account has been exhausted?
Does the health plan reach out to those with chronic diseases to educate them about how to most effectively manage their health care?

BHM Healthcare Solutions specializes in URAC accreditation and URAC consulting. For more information regarding URAC accreditation assistance, please visit the URAC page of our website or call for a fee consultation call BHM at 1-888-831-1171 today!

The Importance of Engaging a Transaction Expert – Part Four

Posted on March 29, 2012 by Tom Bednarek

Finding the right fit is essential in business.

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Mark Twain

The unstable and rapidly changing environment of today’s healthcare marketplace has intensified the interest of healthcare executives, physicians and business owners in the benefits of merging with, acquiring or being acquired by another entity with a common vision. When undertaking these endeavors there are many advantages to be gained, but there are many pitfalls that must be circumnavigated. In this posting I’ll share my thoughts on the importance of engaging a transaction expert to help assure an effective and efficient process.

When opportunity knocks you may want to look through the peephole before opening the door. The decision to embark on a merger should be made only after performing a feasibility analysis that examines key indicators such as financial advantages, operational compatibility, agreement among the parties about what the transaction is expected to accomplish and whether or not the newly formed entity would in fact generate business benefits not possible if each entity remained solo. The fact of the matter is that some prospective suitors may have hidden agendas and you do not want to be adversely impacted by the burden of their financial or operational difficulties.

Once the proposed transaction passes the feasibility analysis, what follows is a time consuming and complicated process. Because of their broad experience, transaction consultants see a wide set of business scenarios in diverse, as well as common, business models. This range of experience will serve to accentuate the transaction’s benefits and be of great help if unexpected issues arise; and unexpected issues almost always arise. The consultant can effectively deal with each issue and move the transaction to completion.

The consultant will also help you leverage your time. Successful transactions require a tremendous amount of communication and coordination with the various parties involved, including but not limited to, you and your management team, the management team from the other company, outside accountants, attorneys and numerous support groups such as medical billing/collection firms. As the transaction process ensues you still have a business or a practice to run. If the attempts at a transaction fail, and most of them do, you do not want to exit the process with a diminished organization that is in need of repair.

The seasoned transaction consultant also brings a wide set of relationships. Perhaps most importantly, if the decision is definitively made to find a suitor and the initial transaction does not come to fruition, then the consultant can not only pinpoint strategic buyers within the industry, but they also have relationships with other potential buyers, such as private equity groups that, in fact, typically pay more than a strategic buyer.

A good transaction consultant is also a financial expert. The components of a transaction are often complicated and you can leverage their financial acumen to fetch the highest price possible for your organization. Effective communication with the various internal and external accountants is imperative, so the ability to navigate through, understand and apply the content of complicated and voluminous financial statements will provide many benefits to your cause. The importance of the benefits you will receive from this understanding of the financial intricacies of the deal cannot be overstated.

It is important for executive leaders to know how much they don’t know. Utilizing the talents of a transaction consultant during the merger & acquisition process will help you achieve the outcome you desire, and help you avoid learning expensive lessons along the way.

To schedule a one to one free initial consultation with one of BHMs leading healthcare consultants please email us at results@bhmpc.com or call us at 1-888-831-1171. BHM consultants provide real value and measurable results to healthcare firms, government agencies, and insurers through data driven and strategic management analysis, and assist organizations with Clinical Operations, Financial Management Improvement, Physician Advisor Services and Accreditation.

Is Your Organization Creative Enough to Meet the Challenges of Adversity? – Part Three

Posted on March 27, 2012 by Tom Bednarek

Creative strategies are essential in today's economy.

“Frugality without creativity is deprivation.”

- Amy Dacyczyn

Credit is tight, consumer confidence is low, and you have the growing realization that increasing the net profit shown on your income statement is as much a function of lowering expenses as it is attributable to boosting revenue. When austerity measures are undertaken your creativity can often times make the difference between success and failure. In this posting I’ll identify some creative measures that will help you successfully grow your business during times of economic malaise.

The first thing you have to determine is whether or not your organization embraces change, and its driving force which is creativity. To make an accurate assessment you can ask yourself when was the last time that you: entered a new market, did something innovative, utilized social media, sought out a strategic partner or rolled out a new product or service. If the prevailing answer is either “I can’t remember,” “not lately” or “never,” then you may want to acknowledge that the first step in solving a problem is admitting that you have one. If the prevailing answer is “what was the question?” then you may have larger issues that need to be addressed.

The fact of the matter is that cost effective solutions exist for those who are not satisfied with the status quo. Here are a few techniques will not only help your business meet the challenge of adversity, but they can provide benefits to your organization in perpetuity.

Utilize Joint Ventures: A joint venture can offer an array of economic benefits to both partner organizations through access to: new geographic markets, complementary products and/or services, additional distribution networks, increased capacity, additional staff skill sets, purchasing economies of scale, technology/intellectual property, and financial resources.

Identify and Nurture Thought Leaders: Unfortunately it is not uncommon for people in organizations to laugh at new ideas and look down upon other employees that point out problems. In the March 5, 2012 issue of Forbes, Shel Israel provides the following definition: “A thought leader is someone who looks at the future and sets a course for it that others will follow. Thought leaders look at existing best practices then come up with better practices. They foment change, often causing great disruption.” It costs you little more than a bit of time and a pat on the back to tap into the benefits that these individuals can provide your organization.

Outsource: Two heads are better than one, and in the constant pursuit of access to the finest human capital outsourcing provides the most cost effective exposure to a more diverse base of skill sets and core competencies that have a proven track record of success.

Leverage Social Media: Social Media can help your organization better understand, respond to, and attract the attention of its target audience. It allows you to get your message out fast, and to a large number of people. Unlike traditional media, Social Media provides the added benefit of being able to instantaneously generate customer feedback which will allow you to gain insight into your target market and identify new product or service opportunities. If used creatively it also allows you to track your competition, quickly identify problems with your product and drive people to your website, thereby improving the ROI vis a vis your technology CAPEX.

If your desire is to cultivate creativity then it is incumbent upon you, as an executive, to inspire your employees to become innovators by virtue of a corporate culture that embraces change. If you proactively inspire change and innovation then your organization will circumvent obstacles encountered during lean times and reap many rewards for years to come.

To schedule a one-to-one free initial consultation with one of BHM’s leading healthcare consultants, please email us at results@bhmpc.com or call us at 1-888-831-1171. BHM consultants provide real value and measurable results to healthcare firms, government agencies, and insurers through data-driven and strategic management analysis, and assist organizations with Clinical Operations, Financial Management Improvement, Physician Advisor Services and Accreditation.

In Crisis Management, Your Silence is Deafening-Part Two

Posted on March 24, 2012 by Tom Bednarek

Communication in business is crucial to success.

“A good plan violently executed now is better than a perfect plan executed next week.”

General George S. Patton

If you are in business for any length of time, sooner or later, you will be exposed to a crisis that can affect not only the company you work for, but your career as well. We have all experienced a vitriolic situation with a friend or family member that, once resolved, ultimately resulted in a stronger bond between the two individuals. In this posting I’ll discuss the assertions that effective communication is the key to crisis management and how timely and effective communication can actually result in a stronger organization.

Organizations that either don’t react, react slowly, or react improperly to adverse events will likely see erosion in brand equity, and in many cases, see forced resignations and firings at the C-level. As a native son of Pennsylvania I am aware of no better example of poor crisis management than what resulted in the wake of the sex abuse scandal that rocked Penn State University in late 2011. The adverse effects of this modern day Greek tragedy on Penn State resulted as much from poor communication as they did from the criminal behavior of University officials. A partial list of missteps includes: no visible leadership once the scandal broke, no message to the public for days, (which fueled the fire, let speculation run rampant & allowed the angry mob of public opinion convict coach Paterno without so much as a whiff of due process), and holding an obviously incendiary news conference late at night…did they really think there wouldn’t be an alcohol fueled student uproar?

The bottom line is that the public hates the unknown. If they know of trouble, but don’t have vision as to the likely outcome then the company stock, its corporate brand, and the personal brands of corporate executives and board members will be severely penalized. In the Penn State scenario the public’s perception of Penn State and its leadership began to be shaped by the speculation and innuendo of the media zealots and other third parties, which differed radically from the facts of the situation.

In smaller organizations, even though a crisis may be largely confined to the four walls of your company you must keep in mind that the same principles apply. What your employees crave is clear, concise, and open dialogue in times of trouble. You must proactively shape the opinions of others as opposed to having others determine the perception of your corporate and personal brand. By being proactive in your approach to crisis management you turn breaking news, speculation and innuendo into old news by putting a face to a position. By taking a visible and open position, you will take the natural desire to create a corporate villain, and turn this instead into a positive outcome by offering evidence of a corporation and executive team that operates with honesty and transparency by taking swift, prudent, and corrective action address to the problems at hand.

When a crisis occurs you can run but you can’t hide so you have a choice to make. You can put your head in the sand and ignore the problem, you can skirt the issue, or you can take the bull by the horns and simply do the right things. Delaying the inevitable will result in increased scrutiny and eventually produce substantial negative consequences. Prompt communication is imperative to producing positive results. Get the issues out in the open, adopt a position, and do the right things regardless of short-term cost. If you subscribe to the latter tact as opposed to either of the former, you will give yourself the best chance of coming out on the right side of the fray and achieving enduring benefits to your organization.

Are You Positioned to Grow in an Improving Economy? Part One

Posted on March 21, 2012 by Tom Bednarek

: There are ways to improve your business.

“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” Martin Luther King, Jr.

Regardless of what the economy is doing, as an executive you are still responsible for creating growth. Although it seems counter-intuitive, prosperity in an improving economy is not a foregone conclusion. Metaphorically speaking, your ship can be severely damaged or even sunk by the economic storm it has just endured. Tough economic times are no excuse for a lack of performance, and in fact, they are all the more reason to focus on catalyzing innovation and growth. In this posting I’ll share my thoughts on how to successfully lead your business out of an economic downturn.

Lagging economic data is not the information you should use to make strategic business decisions. Don’t wait until there is a formal acknowledgement of a burgeoning economy to start planning how you’ll navigate out of tough times. Rather, use the many present forecasting signs of an improving economy (better job growth, rising dollar, more availability of capital and credit, growing retail sales, greater consumer confidence, correcting stock market, mundane inflationary trends, etc.) to adjust your strategy and tactics. This is easier said than done because the long, devastating recession has made maneuvering difficult.

The lack of clever and proactive thinking by your executive team in an economy that is poised to improve can make it much more difficult to survive the large challenges that likely lay ahead. If you are like me you, then you regularly hear statements like: “I’m concerned about the stability of the economy, and want to wait and see how everything shakes out before I make any decisions”, or “I’m cutting back on all expenditures until I see how bad healthcare reform is really going to get.”

The simple truth of the matter is that rewards exist for those astute enough to move forward and strategically leverage their business model to exploit opportunities while their competition pulls back and braces for tough times. The following business principles will help your business thrive regardless of the state of the economy:

Outsource: Be very strategic about bringing on new employees. Only make key hires that produce an immediate and significant impact. It has been proven time and again that the most chaotic and financially inefficient implementations are conducted with new employees.

Keep Growing. Stay aggressive while your competition pulls back, slashes costs, and has their heads in the sand. While it is certainly necessary to reduce frivolous expenses, resist the temptation to cut budgets in the areas of sales, marketing, and business development.

Outsource: There is significant leverage to be had in outsourcing implementations to competent experts. Outsourcing frees your internal resources to focus on activities that allow for continuity of your mission.

Leverage Technology: Use technology to provide increased efficiency. Strategic investments into process improvement will allow you to weed out system inefficiencies. If your company replaces innovation with caution and pervasive cost cutting, you will not only find survival more difficult, but if you’re still around when the economy recovers you will find yourself at an operating disadvantage compared to more savvy competitors who did not make the same mistake.

Outsource: Outsourcing will offer the following benefits: shorter time frame to implementation, more cost effective implementation, access to existing toolsets and solution sets that have a proven track record of success, access to a more diverse base of skill sets and core competencies, access to best in class human capital within the area of domain expertise required, and reduction of investment into infrastructure expenditures.

In a down economy the stakes are higher, the money and resources are tighter, and the tactical decisions made by you and your management team will be the difference between success and failure. If your management team can streamline operations, deliver solid strategic planning, conduct a prudent execution of business initiatives, and retain best in class human capital (both organically & via outsourcing), your business will gain ground while your competition is stagnating and will be properly positioned for accelerated growth during the next economic boom.

You Should Be Excited About This…..

Posted on March 15, 2012 by Danyell Jones

Have you ever wondered how you can improve your business in a down or rebounding economy?

Has your organization ever had the necessity for a crisis management strategy?

How are you dealing with adversity, and are you aware of the importance of engaging and expert to assist in growth?

I am excited to announce that we will be not only be having a guest poster in the upcoming week who will address these questions and more, but we are pleased and excited to have such a prestigious guest on our blog. Mr. Tom Bednarek will be offering invaluable advice this upcoming week on everything from business strategy, to how to handle a crisis situation, and how to best address the challenge of adversity. Our followers are welcome to submit comments and questions and will have live access to one of the nations leading healthcare executives…..so bring your questions and comments, we would love to hear from you!

Tom Bednarek is a Senior Consultant with BHM Healthcare Solutions and is responsible for providing key support for corporate strategy, operations and business development initiatives. Prior to joining BHM, Tom founded Beacon Acquisition Solutions to provide strategy M&A and business development advisory services to mid-market healthcare companies. Starting in 2008 Tom was named Chief Executive Officer of Premier Radiology and Affiliates, a regional provider of radiology services. While at the helm he initiated a successful turnaround of the organization and his initiatives eventually guided every component of the organization to profitability. In addition to these positions Mr. Bednarek was the Managing Director and Division President of Commercial Property and Investment Banking Services at Watermark Properties Group where his primary focus was healthcare mergers and acquisitions.

Questions to Ask Before Having a Radiology Test

Posted on March 6, 2012 by Annie Evans

With the state of our economy and the rising cost of health care, medical scans such as MRIs, PETs, or CT scans can seem particularly expensive. Policymakers claim that physicians who prescribe these tests often do so just to make money. However, these types of scans have also greatly improved the quality of health care we receive today.

If your physician prescribes any type of radiology test, it’s natural to feel concerned and overwhelmed about both the procedure and the cost. Before you have any such test done, there are a few questions you should ask your doctor to make sure that it is absolutely necessary and safe.

1. Why do I need this test?

Don’t be afraid to ask your physician why you must have a certain test done. Ask what information it will provide and how the results may affect your treatment. Advanced medical imaging scans can provide excellent information, but they should not simply be a replacement for a physical exam.

2. What are the risks and side effects of this test?

It’s important to know the risks of the radiology test your physician prescribes, so that they can be compared with the potential benefits of having such a test.

The main risk of advanced medical imaging is exposure to electromagnetic energy, which varies depending of the type of scan.

- Magnetic Resonance Imaging scans (MRIs) use a magnetic field which is safe to most patients. However, if a patient has a pacemaker, automatic defibrillator, or other metallic articles in their body, an MRI is not safe.

- Computed Tornography (CT) scans use high levels of ionizing radiation at about 300 times more than the exposure of an x-ray. Although they are still relatively safe, pregnant women should avoid these types of scans.

- Positron Emission Tornography (PET) scans are performed with a nuclear source but are considered safe for most patients

Another risk is an allergic reaction to a substance called contrast, which is a dye injected into the veins to produce a clearer image. Allergic reactions are very rare, but may be more likely if you have a history of diabetes or kidney problems.

Thirdly, advanced imaging techniques can expose other abnormalities in the body that may or may not be a health problem. A physician may recommend further testing to ensure that there is not a problem, which will result in more scans and increased costs.

3. How much will this test cost? Are there any low-cost alternatives?

While prices of imaging tests vary, CTs generally cost less that MRIs or PET scans. In some cases, less expensive imaging options like an x-ray or ultrasound can provide your physician with enough information. Other times, the results of blood tests or other tests will offset the need for radiology testing.

4. Where should I have this test done?

Not all medical imaging facilities are alike. Some may have newer equipment that produces better images, or they may have a staff with more experience. You should go to a center that employs certified or licensed technicians and a board certified radiologist. The equipment should be up to date and FDA approved. The center should also take proper measures to ensure safety from radiation and magnetic fields. Most importantly, the center should be known for producing quality results.

5. How soon do I need to have this test performed?

Most radiology tests do not need to be performed immediately. Consult your physician and consider how long your health problem has been present and if it has improved. Many problems should be treated a fair amount of time before medical imaging is performed.

Annie Evans has been working as a certified radiologist in hospitals for over 15 years. Her site, Become an X-Ray Technician, is a resource for students who want to start a career in medical imaging.

Heart Attack Research Reinforces New Preventative Health Strategy

Posted on February 29, 2012 by Imogen Reed

Heart attacks are one of the leading causes of death in American men and women over 55. While men are more likely to suffer a heart attack than women, fatalities among women heart attack sufferers is far higher, and new research has discovered the possible reason for this. While symptoms of heart attack are often well publicized, with chest pain being the most obvious, research has discovered that fewer women suffer from these classic symptoms than men, making missed diagnosis far more common.

Whether under Medicare or with private surgery insurance, diagnosing and preventing heart attacks is a primary concern for all health care providers, and under the Affordable Care Act, is one of the primary preventative care strategies for Medicare. One in three Medicare patients die due to cardiovascular disease, but the risk is far greater for women than it is for men. Currently, a heart attack is fatal in around 10 percent of male Medicare patients, while for women, fatalities occur in about 14 percent of heart attacks.

New Research

Heart disease is the leading cause of death in all Americans over 55, but the research has found that the risk of death is greater for women, because they don’t always suffer chest pain, often thought of as the primary symptom of a heart attack. Because of this, researchers believe many women are not getting the right type of treatment as the heart attack is not being diagnosed.

Writing in the Journal of the American Medical Association, the researchers say their study, compiled in 1000 hospitals throughout the United States, found 42% of women who suffered a heart attack did not experience any chest pain whatsoever, compared with just 30% of men, and with younger patients, the difference was even more striking.

Despite the difference in symptoms and increase in risk of fatalities, researchers found men still suffer significantly more heart attacks in the United States than women, and cardiovascular disease tends to strike men at a younger age too; the study found that the average age of a male heart attack sufferer was 67, while for women it was 74.

Symptoms

Prompt treatment is the key to heart attack survival in all patients, regardless of sex, so it’s important that people can identify symptoms early. Without the presence of significant chest pain, identifying the symptoms of cardiovascular disease can be extremely difficult. Some patients report only breathlessness, a feeling of being unwell, and a feeling not unlike indigestion. Researchers believe this could mean than tens of thousands of American women may have suffered a heart attack and not sought any treatment, having put down the condition to indigestion, heartburn or summer other minor ailment. However, the likelihood of permanent heart damage and a repeat attack is far greater after such an episode, even if the heart attack symptoms were only mild.

Besides severe chest pain, any of the following symptoms could be indicative of a heart attack:

A dull ache, heavy feeling or mild discomfort in the chest
Pain in the back, arm or stomach
Indigestion that feels either severe or prolonged
Feelings of light headedness or dizziness

Prevention

An increasing emphasis is being placed on prevention of heart attacks and this new research suggests the importance of the preventative health measures introduced the Affordable Care Act. Medicare now covers more preventive health services aimed at helping people reduce the risk of heart attack. It is hoped, that the Million Hearts Campaign, which Medicare are helping to lead, will prevent a million heart attacks and strokes over the next five years – this could mean the saving of nearly 200,000 American lives.

Starting from American Heart Month, which began in February, Medicare will pay for an annual face-to-face visit so that Medicare beneficiaries can discuss ways to prevent cardiovascular disease with their care provider. During this visit, care providers will screen patients for high blood pressure, whilst also providing advice on healthy eating and ways to change lifestyle habits that could reduce the risk of cardiovascular disease in the future. While smokers, people with diabetes and those suffering obesity – the leading causes of cardiovascular disease in the United States – are also now entitled to claim for counseling services under Medicare since the Affordable Care Act.

RAC Learning Series Part Four – Demystifying the Query (Audit) Process

Posted on January 17, 2012 by Vickie Axsom Brown

Demystifying the Query (Audit) Process

Vickie Axsom-Brown, Senior Consultant, BHM Healthcare Solutions

BHM assists organizations mitigate RAC audit risk

Demystifying the Query Development process is key to every health care provider’s success regardless of the type of services delivered. It requires an understanding of the resources, references and tools used by RACs so providers can maintain their organization’s preparation for CMS audit “participation.”

The tools used by RACs are vast and may look like alphabet soup. The “New Issue” process begins with the responsible team’s identification of potential billing/reimbursement issues. The typical “New Issues” team is comprised of experienced claims’ processing representatives with Part A, Part B, DME, pharmacy, home health, hospice, hospitals, providers, SNFs, et. al. specific backgrounds. This team uses their experience and multiple resources to identify potential issues for which analysis will be done to validate issue value.

In addition to experience, the following data sources are used (the alphabet soup):

Raw Data – RAC database, routine CMS RAC Data Warehouse downloads, industry trends…
Outcome Reports – CERTs[i], OIG[ii], PEPPER[iii], GAO[iv], QIOs[v]….
Industry Experience[vi] & Information – AAHAM, AHA, AMA, AAASC, JCAHO, JCAHACO…
Policy/Rules and Regulations[vii] – LCDs, NCDs, CRs[viii], IOMs, MLN…
CMS Programs – ZPICS[ix], DOJ[x], Vulnerabilities Reports[xi], Carriers, FIs, MACs

Information is collected and evaluated to determine potential improper payment trends, type of provider(s) involved, resources and financial impacts, and projected outcomes. Data are analyzed by statisticians and/or SAS analysts to define the each of these elements by targeted provider type(s). Once analytical results are provided to the New Issue team, the list of improper payments is prioritized and the New Issue submission type/preparation begins.

Different submission criteria exist for New Issue automated reviews (examples of findings and results required) and New Issue complex reviews (medical record documentation and evaluation findings required). The RACs preparation and submission processes vary due to CMS Review Board supportive information/analytical requirements and can range from 30 to 120 days preparation prior to RAC submission to CMS.

All New Issues require complete data presentation with projected Medicare Trust Fund returns. The CMS New Issues submission package is well-defined and must meet all specifications before presentation to the CMS Review Board. If a New Issue package fails any defined criterion, it is returned to the RAC for re-submission. This means the RAC loses a place in line for the CMS Review Board’s review/approval of a New Issue. 2010, the CMS New Issues Review Board had an ever-increasing New Issues backlogs resulting in their encouragement that all RACs collaborate on a list of New Issues for Board consideration. RACs pursued the recommendation and drafted eight (8) New Issues for collaborative submission to the CMS Review Board.

Upon receipt of a New Issue package, designated CMS Review Board representative(s), review(s) the package for submission compliance, content, New Issue review type (automated/complex), value (financial returns), and review submission direction. The New Issue package may be presented to the RAC Validation Contractor for assessment and recommendations and/or to the CMS Review Board (physicians, policy makers, et. al.). Once reviewed, the CMS Board generates a decision:

1- Approved as submitted.

2- Approved with modifications.

3- Approved with defined limitations.

4- Denied for current review period, resubmit in one year.

5- Denied.

Approved New Issues are posted on the RACs’ provider portals and are available for the RACs inclusion in future audits.

[i] Comprehensive Error Rate Testing (CERT) Program reports (www.cms.gov/CERT/CR/LIST.asp. Lists reports by hear and Report Type, e.g., Over utilized codes, CERT findings, Use corrective actions to monitor improper payment findings. This website usually accessible from Carrier/FI/MAC Website link.

[ii] Office of Inspector General Reports (www.hhs.gov/reports.asp

[iii] Program for Evaluating Payment Patterns Electronic Report (PEPPER); Published by TMF Health Quality Initiative under contract with CMS…Audio on demand for Pepper information; PEPPER 2011: Identify Changes, Address Vulnerabilities and Be Audit-Ready

[iv] General Accounting Office “GAO” Reports (www.gpoaccess.gov)

[v] Quality Improvement Organization Reports, www.cms.gov/QualityImprovementOrgs/

[vi] Inpatient, Ambulatory, Outpatient, DME, SNF, CORF, Rehab, Hospice, Physician, et.al.; www.beckerhospitalreview.com; high risk coding errors, duplicate claims, pricing errors, billing excessive units, failure to meet LOC requirements, payment errors, SNF consolidated billing, cross over coverage (ambulance, medications, ), questionable level of care, improper diagnosis codes, mismatched codes, et.al.

[vii] Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) www.cms.gov/medicare-coverage-database/

[viii] CMS Change Requests www.cms.gov/Transmittals/downloads

[ix] Zone Program Integrity contractor – ZPICs (former Program Safeguard Contractors) www.zpicaudit.com

[x] Department of Justice, www.justice.gov/oig/reports/index.htm

[xi] Vulnerability Reports (multiple references); www.gao.gov – Spotlight or Key Issues section or www.gao.gov/docsearch/repandtest.html

RAC Learning Series Part Two – New RAC Statement of Work

Posted on January 5, 2012 by Vickie Axsom Brown

RAC ALERT

NEW RAC STATEMENT OF WORK

BHM assists organizations prepare for RAC audits

Vickie Axsom-Brown, Senior Consultant, BHM Healthcare Solutions

In the recent year a Centers for Medicare & Medicaid Services (CMS) Cms.hhs.gov- Recovery Audit Contractor Update was generated. The new update was the 090111 Recovery Audit Program Final SOW [PDF, 292 KB] (an updated State of Work for the Recovery Auditors). Several key areas were revised, updated and/or clarified. A summary of these include:

Recovery Audit Contractors revised to Recovery Auditors.
Additions and Clarifications that the Recovery Audit Program includes ALL contracts, all types of claims with the focus being on lower error rates and identifying improper payments with the greatest impact on the Trust Fund to prevent misunderstandings. Medicaid RAC documents have referred to Medicare Recovery Auditor focus limitations as acute care facilities.
Addition of a new type of review – “semi-automated review” a new 2 part review process which can include both automated and complex reviews. This review type does not pay providers for medical record submissions.
Clarification of DRG Validation versus Clinical Validation by adding definitions.
Addition of language for “Allowance for a Discussion Period” to clarify this process – e.g., an escalation process for the discussion period, where a physician (or a physician employed by the provider) may request to speak to the Recovery Auditor physician and new directives that once an appeal is filed with the MAC, the discussion period must be discontinued. This minimizes duplications of effort by the Recovery Auditor and MAC.
Change to the Recovery Auditor website’s listing of new issues whereas the new issue list must be sortable by a minimum provider type by June 1, 2011.
Addition that CMS reserves the right to share new issues with all CMS review entities. (Collaboration)
Clarification of Recovery Auditors and MACs roles.
Addition of Recovery Auditor activities when CMS refers potential improper payment notices (Technical Direction Letter) to them.
Further clarification on the Adjustment Process as it relates to associated findings.

More information to follow….

[i] Medicaid RAC FAQ, Question 13, “You stated that the scope of the Medicaid RACs must be “broad”. Can you expand on this?”