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"RACaphobia" Print E-mail
Written by Bill Gompers   
Saturday, 05 March 2011 15:04

RACaphobia is defined as an intense and persistent fear of an RAC Audit.  As we have all become aware, RAC is an acronym that stands for Recovery Audit Contractor.  These contractors are charged with the responsibility of implementing the Centers for Medicare & Medicaid Services' (CMS) program to mitigate overpayments to providers.  In addition to physicians, virtually all healthcare providers who bill Medicare and Medicaid, such as hospitals, durable medical equipment companies, home healthcare organizations and nursing homes, are the targets of these audits.

The RACs are extremely motivated to uncover overpayments to the healthcare providers they audit because a large part of their remuneration is based on the amount of improper payments they unearth.  In fact, many sources have likened RACs to "bounty hunters" being paid a contingency fee of between 9% and 12% on the recovered overpayments.

Among the findings reported during the demonstration program conducted in Arizona, California, Florida, Maine, New York and South Carolina were:

  • Nearly $1 billion of overpayments were identified based on about 525,000 overpayment determinations.
  • Approximately 20% of the overpayment determinations were appealed, with less than 5% of the reviews being overturned.
  • Only $38 million of underpayments were identified.
  • The costs for running the program were about 20% of the funds recouped.

Because of the demonstration program's great success, the RAC program was mandated across all 50 states in 2010.  As part of the 2010 Patient Protection and Affordable Care Act, the RAC program has been expanded to include Medicare Part C, Medicare Part D and Medicaid.

In order to limit exposure, many experts recommend the following:

  • Know what the RACs are looking for and assess whether these issues occur within your practice. This information can be found on each governing RAC website.
  • Conduct internal audits to identify potential overpayments and develop a corrective action plan to reduce the risk of future overpayments.
  • Consider moving toward and utilizing an Electronic Medical Record (EMR).
  • Utilize certified billing and/or coding experts on a yearly or biennial schedule to conduct reviews, ensure compliance, update templates and train staff on issues involving coding and billing.
  • Make sure your billing staff is properly qualified, trained and provided with continual training/updates as to the audit process, applicable Medicare and Medicaid guidelines, and coding and billing practices.
  • Select a higher-level point person within your practice who will handle all RAC requests and future communications. This will ensure that the process goes more smoothly.
  • Understand the appeal process in order to ensure that no deadlines are missed.

As part of their planning process, many providers are looking for ways of defraying the costs of legal defense, fines and penalties associated with RAC Audit determinations.  Insurance coverage to help meet this need can now be purchased in the marketplace.  This coverage is very inexpensive and should be considered to alleviate sleeplessness associated with "RACaphobia."

After a year of audit expansion, providers can expect to see increased audit activities as we move further into 2011. Since almost all providers will be involved with an RAC audit, it is important that they prepare and address these issues with their trusted advisors

Bill Gompers is a medical malpractice insurance specialist with Danna-Gracey, a boutique insurance agency specializing in medical malpractice and workers compensation for Florida's medical community. To contact him call (305) 775-1960 or (800) 966-2120, or e-mail bill@dannagracey.com.

Last Updated on Wednesday, 23 March 2011 08:13
 
Rules and Policies for Treating Non-English Speaking Patients Print E-mail
Written by Jeffrey Segal, MD, JD and Michael J. Sacopulos, JD   
Thursday, 24 February 2011 10:13

"What we have here is a failure to communicate."

  According to the 2000 U.S. Census 18% of people living in the U.S. spoke a language other than English in their home.[1] Jump ahead 11 years and that number continues to grow. We are asked to press one for English and have the option of reading everything from a manual to a menu in Spanish. While Spanish is the second most spoken language here in the U.S., there can be regional variation.

Of the more than 18% who don't speak English as their first language, most, if not all, will see a physician here in the U.S. at some point. The physician they choose may not speak their native tongue.

According to a 2009 UCLA study 13% - nearly 31,000 patients who have asthma problems in California - experience problems understanding their doctors. This rate is more than three times higher than those who speak English very well (or who are native English speakers). The rate of ER/Urgent care visits for asthma patients who struggle with English is 77% higher than for similar patients who can communicate with their doctor. This adds to the number of unnecessary, expensive ER visits.[2]

Title VI of the Civil Rights Act prohibits discrimination based on race, color or national origin.  The Act goes even further in protecting against discrimination of those with limited English proficiency - also known as "LEP".

Health care providers receiving Federal financial funds are mandated by law to take adequate steps ensuring those who can't speak English are provided with the necessary tools to clearly communicate with their physician.  Physicians who are unsure whether they receive financial assistance should think twice.  Physicians who receive reimbursements from Medicaid or Medicare are recipients of Federal financial assistance, and, thus must comply with Title VI requirements for language assistance. 

The challenge goes beyond compliance with government rules.  Failure to comply can also result in civil liability claims.  In 1999 Omar Aghazadeh visited the Maine Medical Center. Aghazadeh spoke Farsi; not English. Because of the language barrier; Aghazadeh asserted that he did not receive the proper treatment. He filed a law suit - in English.  This suit distilled to the claim the patient was discriminated against merely because he did not speak English.[3]  

The type of language assistance that must be provided to LEP patients depends on a variety of factors including:

-The size of the medical practice

-The size of the LEP population

-The nature of the service

-The total resources available to the medical practice

-The frequency with which particular languages are encountered

If the Office Civil Rights ("OCR") gets a complaint about a noncompliant physician's office, they will inform the practice in writing of its findings and identify the steps that must be taken to become compliant. If the practice chooses to ignore the OCR's helpful hints,  the OCR is empowered to terminate any Federal funding (after an administrative hearing).  

To read the complete story CLICK HERE.

ABOUT THE AUTHORS:   Jeffrey Segal, MD, JD, is founder and CEO of Medical Justice Services.  Mike Sacopulos, JD, is general counsel for the organization.  Run by physicians for physicians, Medical Justice, is a membership-based organization that offers proven services and proprietary methods to protect physicians' most valuable assets - their practice and reputation. The company offers proactive services to deter frivolous medical malpractice lawsuits, prevent Internet defamation and provide proven strategies for successful counterclaim prosecution. Medical Justice works as a supplement to conventional professional liability insurance.

[1] http://www.census.gov/prod/2004pubs/censr-18.pdf

[2] http://www.healthpolicy.ucla.edu/NewsReleaseDetails.aspx?id=15

[3] Aghazadeh v. Maine Medical Center; 1999 WL 33117182 (D. Me)

 

Last Updated on Tuesday, 22 March 2011 17:14
 
Judicial Hellholes 2010/2011 Print E-mail
Written by Dennis Bartlett   
Saturday, 12 February 2011 14:41

Yes, there is a list called "judicial hellholes". For the last several years, the American Tort Reform Foundation (ATRF) publishes a list of the worse venues of various judicial abuses.  South Florida was the #1 hellhole in 2009/2010, # 2 in 2008/2009 and #1 in 2007/2008.  However, on the new list, South Florida moved to Number 4.  The 2010/2011 list is:

1.     Philadelphia

2.     California - especially Los Angeles & Humboldt Counties

3.     West Virginia

4.     South Florida

5.     Cook County, Illinois (Chicago)

6.     Clark County, Nevada (Las Vegas)  

ATRF also has a watch list for those venues that could easily slip to the top Hellhole list depending on changes in their litigation climates. These venues include:

  • Madison County, Illinois
  • Atlantic County, New Jersey
  • St. Landry Parish, Louisiana
  • District of Columbia
  • New York City & Albany, NY
  • St. Clair County, Illinois
  • Mclean County, Illinois
  • Gulf Coast of Texas

Judicial Hellholes are considered places where judges systematically apply laws and administer court procedures in an unfair and unbalanced manner that usually ends up with defendants having a much tougher time to get a fair and impartial trial. They permit liability-expanding theories and strategies, Class Action suits are usually a major part of the problem, as plaintiff attorneys shop for the most plaintiff friendly venues (pharmaceuticals, asbestos cases and tobacco industries are heavily affected), Philadelphia courts allow "reverse bifurcation", in asbestos trials, where the juries decide how much money plaintiffs should get before considering if defendants are responsible for the alleged injuries.  I'm aware of a class action case in Illinois (one of my clients), who is a defendant in an alleged privacy injury arising out of a fax blast to 5,000 prospects, that could cost insurers over $5,000,000, and that does not include legal defense costs which will be at least in the $50,000 range - all over an event where there is no real injury or damage. 

Florida's legal environment may be clearing due to reform action taken in 2010 by the Florida Legislature. One of the most significant actions was an appellate court in Miami that ruled that the $250,000 limit on pain and suffering in medical malpractice arbitration cases was legal, and applies per claimant, not per defendant. Another appellate court ruling upheld the $500,000 cap on non-economic damages.  That case will probably go to the Florida Supreme Court for final review sometime in 2011 or 2012.  The medical malpractice tort reform enacted in 2003 has resulted in a drop of lawsuits against doctors over the last several years.  Miami Dade also delivered a $14,000,000 award in an asbestos suit (they had a $24,000,000 award in 2008). 

Check out their website and read the report, it's very enlightening and is a scary snapshot at what ails our legal system.  www.judicialhellholes.org.

Dennis Bartlett

Vice President

Employers Mutual Inc.

Last Updated on Saturday, 05 March 2011 15:03
 
P4P Demonstration Project: Results Encouraging Print E-mail
Written by Michael Casanova   
Sunday, 26 December 2010 00:00

    According to a Healthcare Finance News article, CMS reported year four results on its Pay-For-Performance (P4P) demonstration project, stating that the project has realized $98 million in savings, and its participants have qualified for more than $78 million in incentive payments.

As a result of this performance, CMS paid $31.7 million in performance payments to five physician groups. "Based on what we have learned so far, we know the healthcare industry can meet high standards for improving quality of care while saving Medicare money," said CMS Administrator Donald Berwick in a statement. "Now we want to raise the bar."

All that certainly sounds good, but other pundits point out that P4P schemes have unintended consequences that can potentially worsen health disparities for minorities and undermine their care if payments are not risk adjusted. In the article, two recent studies were cited.

For example, Johns Hopkins researcher Martin Makary, MD, found that physicians have more incentive to "pass on, stall or delay treatment" to obese patients in need of gallbladder or appendix surgeries because they're statistically more likely to experience complications than their non-obese counterparts. "We found that practices that treat vulnerable populations have room for performance improvement, so it's important to preserve the incentive to improve quality of care while taking steps to prevent an increase in disparities," said Dr. Mark Friedberg, the study's lead author. His study appears in the May issue of the journal Health Affairs.

As we continue to manage the current national fiscal crisis, expect healthcare to continue to dominate the news. Look for P4P schemes to be more focused toward case outcomes and not just cost-efficiency driven. 

About the Author:  Michael Casanova is a healthcare executive, consultant and author. Should you wish to opine, he can be reached at mykido@live.com.

Last Updated on Tuesday, 22 March 2011 16:56
 
Healthcare M & A Heating Up? Print E-mail
Written by Jeffrey Herschler   
Wednesday, 22 December 2010 18:50
 
       Based on a story in MergerMarket.com, Healthcare M & A is due for an uptick.  In fact, according to their recent survey, 96% of respondents expect an increase or a significant increase. The authors point out that "This bullish response is not necessarily surprising, as the healthcare sector as a whole is facing an increasingly competitive climate as well as increased demand."  
  
However, according to the Walden Group, current deal activity reflects "...uncertainty over the economy, healthcare reform".  Further, "...acquirors therefore are more discriminating." To view their Q3 report, click on this link:   The Strategic Healthcare M & A Report

If you are contemplating a deal, you may want to read McDermott, Will & Emery's article entitled:

Top 5 Potential Pitfalls in Health Care M&A Transactions 

Last Updated on Tuesday, 11 January 2011 16:40
 
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