...Medicare Audits Affecting Healthcare Ecosystem Medicare is the most prominent health insurance program in the world; accounting for two percent of gross domestic production, seventeen percent of the U.S. health expenditures, and one-eighth of the government’s national budget. The major impact that this government payer program has in the healthcare ecosystem is the massive coverage it provides to the elderly and disabled. Costing about $260 billion annually, Medicare inaugurated the Recovery Audit Contractor (RAC) program to make claims more cost effective with the detection of over and under payments. The recovery audit was first drafted through Section 306 of the Medicare Modernization Act (MMA) of 2003 which directed the Department of Health and Human Services (DHHS) to constitute a demonstration of the program. The required program began in 2005 and utilized RACs to isolate and correct inappropriate payments in the Medicare Fee-For-Service (FFS) program. According to the Centers for Medicare and Medicaid Services (CMS) (2014), the demonstration ended in 2008 resulting over $900 million in overpayments and nearly $38 million in underpayments. The success of the audit trial gave CMS a “valuable new tool for preventing future inappropriate payments” (American Health Information Management Association (AHIMA), 2009). This succession brought the recovery audit into legislation under Section 302 of the Tax Relief and Healthcare Act of 2006 which mandated a permanent...
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...payments and recoupment of payments? Because deadlines for appeals were being missed, recoupment of payments with no documentation of reason for recoupment, and one centralized location for tracking audits and appeals needed. Bottom line for a CFO -- is the bottom line. Even with a simple tracking program and patient software for recording payments and adjustments, the administration of audits and appeals needed an overhaul. So after a contracted (government-like) study costing somewhere near $100,000 (L. Emerson, personal communication, October 14, 2014), a new department was recommended to handle any Recovery Audits. The Recovery Audit Response Program department was born. Let’s take a closer look… Evaluate: Who makes up the new department? What are recovery audits? The Centers for Medicare and Medicaid (CMS) was issued a mandate to implement the Recovery Audit program (RACs) to investigate and correct the overpayments made by their Medicare Administrative Contractors (MACs) who are contracted to payment Medicare claims presented by Medicare participating providers. A demonstration program was implemented and running for a year before the Recovery Audit Contractors were chosen. Their directive was to look at a particular number of medical records and determine if Medicare overpaid or underpaid the provider. By looking at the documentation sent by the provider to the RAC, the RAC determined that the documentation supported the payment or fell short of supporting the...
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...The Recovery Audit Contractor or RAC program was created through the Medicare Modernization Act (MMA) of 2003 in order to identify, review, audit and recover improper Medicare payments that were paid to healthcare providers under fee–for-services Medicare plans. There are four RAC’s and each one is responsible for a designated region and each one has its own plan for targeting issues. The RAC program helps providers avoid submitting claims that do not comply with Medicare rules. According to the United States Department of Health and Human Services, they were required by law to make the RAC program permanent for all states by 2010. When the program was first introduced as a demonstration in 2005 it focused on the states of California, Florida and New York. During this time of demonstration the RAC program focused on improper payments made under the part A and B plans of Medicare and had recovered nearly six hundred and ninety three million dollars. Currently in the state of California, The California Medical Association (CMA) is pushing congressional members to co-sponsor The Fair Medical Audits Act of 2015. This legislation will address many issues and concerns that physicians have regarding the lack of clear, expensive, time consuming and unfair process that plagues the Medicare Recovery...
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...improper payments. Examples include the over-use of services or the providing of unnecessary tests. (Another area, "waste," refers to health care that is not effective, and will be the subject of a separate Health Policy Brief.)Endowed with new powers under the Affordable Care Act and the Small Business Jobs Act of 2010, the Centers for Medicare and Medicaid Services (CMS) has been adopting new tools to curb fraud and abuse in the Medicare and Medicaid programs. The new approach amounts to a paradigm shift from the earlier model, in which CMS paid providers first, then sought to chase down fraud and abuse after the fact--a process known as "pay and chase."This policy brief focuses on eliminating fraud and abuse in Medicare and Medicaid and explores the challenges involved in putting the new tools into place. | What's the background? | The true annual cost of fraud and abuse in health care is not known. In fiscal year 2011 Medicare spent $565 billion on behalf of its 48.7 million beneficiaries, while federal and state Medicaid agencies served 70 million people at a combined cost of $428 billion. CMS estimated that in fiscal year 2010 these two programs made more than $65 billion in "improper federal payments," defined as payments that should not...
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...Accountability Office GAO 2009 Act GAO ARRP GAO 2010 2015 GAO GAO GAO GAO GAO The American Recovery and Reinvestment Troubled Assets Relieve Program TARP 2009 4 2010 4 1675 GAO GAO ARRA 2009 ARRA TARP TARP GAO 61 GAO 2012 3 2001 GAO GAO 2000 GAO No Child Left Behind Act 2011 1982 GAO 3 10 14 SBIR 1986 1992 GAO GAO the Centers for Medicare & Medicaid Services CMS GAO CMS (Medicare) Medicaid CHIP GAO Cost-Effectiveness Analysis Environmental Protection Agency CEA 2005 Cost-Benefit Analysis GAO CBA CBA GAO GAO GAO GAO GAO 2009 GAO 2009 GAO 3 30 GAO GAO 1993 62 2012 3 GAO GAO GAO GAO 2008 2012 63 2012 3 GAO . 2010. . 2010. [J]. [J]. 7 . 2 . GAO. 2011. Southwest Border: Border Patrol Operations on Federal Lands, Washington DC No: GAO-11-573T. GAO. 2011. Refugee Assistance: Little Is Known about the Effectiveness of Different Approaches for Improving Refugees’ Employment Outcomes, Washington DC No: GAO-11-573T. GAO. 2010. STRATEGIC PLAN 2010-2015. GAO. 2010. Recovery Act: Opportunities to Improve Management and Strengthen Accountability over States' and Localities' Uses of Funds. Washington DC No: GAO-10-999. GAO. 2010. Recovery Act: Further Opportunities Exist to Strengthen Oversight of Broadband Stimulus Programs. Washington DC No: GAO-10-823. GAO. 2010. Recovery Act: States' and Localities' Current and Planned Uses of Funds While Facing Fiscal Stresses...
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...Assignment 2: Accounting and Audit Enforcement ACC 599 – Graduate Accounting Capstone QUESTION #1 After so many scandals in regards to financial frauds, Sarbanes-Oxley Act Section 404 mandates that all publicly-traded companies must establish internal controls and procedures for financial reporting and must document, test and maintain those controls and procedures to ensure their effectiveness. Non-for-profit healthcare organizations do not hold themselves to the same standards as the for-profit organizations. Although whether SOX guidelines apply to businesses in the healthcare industry depends on whether the business is a for-profit or non-for-profit organization, some voluntarily adopt SOX in an effort to strengthen internal management controls and increase the quality of healthcare financial reporting (Lohrey, n.d., ¶1). Non-for-profit organizations could certainly benefit from the SOX Section 404 to help reduce the possibilities of corporate fraud by increasing the stringency of procedures and requirements for financial reporting. Many health care executives and board members have concluded that SOX created a new benchmark for best practices, as well as provided extra protection from liability by evidencing direct board attention and oversight of organization compliance (Kusserow, 2013, ¶1). Without audit committees, non-for-profit organizations are at higher risk of financial disaster. Following the SOX compliances can be very beneficial for the non-for-profit...
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...physicians to bill for a constructed rate due to the complexity of the diagnosis. For instance the ICD-9 diagnostic code 821.11 is for an open fracture of shaft and the updated ICD-10 code is S72.352C for a displaced comminuted fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB or IIIC (Convert ICD-9-CM 821.11 to ICD-10-CM., n.d.). Providers receive payment based off these diagnosis codes, and if bundled together, payment is based off the DRG; diagnosis-related group. I would not agree on the recommendation of recovering revenue lost my Medicare by reducing the physician payments. The recovery should of the providers that choose to fraudulently submit claim to Medicare for reimbursement. Medicare needs to conduct more provider audits and to make sure that the billing integrity of all providers. Penalize those that are wrong and implement a better recovery audit program (Overview, 2017). I would disagree with higher payments for facility-based services that can be performed in a lower-cost setting should be eliminated. Regardless of the setting where the services are provided, it is the quality of care that is being done by the provider that is most essential. Providers should be paid based on its service and not where it is performed. Whether a service is done in the home or at a facility, nevertheless, the same procedure is being done (The National Commission on Physician Payment Reform). In conclusion, provider payments are convoluted...
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...Dealing with Fraud Liquid Professor Beharry Health Care Policy, Law, and Ethics March 18, 2013 Abstract This paper will evaluate how the Healthcare Qui Tam affects health care organizations while providing (4) examples of Qui Tam cases that exist in a variety of health care organizations. Other responsibilities discussed, are devising a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals; the ability to recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth. The know how to devise a plan to protect patient information that complies with all necessary laws. Evaluate how the Healthcare Qui Tam affects health care organizations. The Healthcare Qui Tam affects health care organizations in that well over more than 450 hospitals across the country were the subject of Medicare fraud investigations. Whether or not Medicare violations are found, the costs of responding to an investigation can be significant. Westchester Medical Center of New York, being investigated for possible health care fraud and violations of anti-kickback laws, received a subpoena for extensive records in some thirty-seven categories going back to 1997. Millions of dollars may be spent in legal fees and other costs associated with the investigation (e.g., hiring or reassigning staff to assist with compiling...
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...T ackling Fraud, Waste, and Abuse in the M edicare and Medicaid Programs: R esponse to the May 2 Open Letter to the Healthcare Community Dan Olson, CFE June 2012 Tackling Fraud, Waste, and Abuse in the Medicare and Medicaid Programs White Paper C ontents I. Introduction ............................................................................................................ 1 II. Recommendations................................................................................................... 3 Recommendation 1 – Expand the Medicare Fraud Strike Force Model....................................... 3 Potential Savings .......................................................................................................................... 4 Recommendation 2 – Expand Integrated Data Repository .......................................................... 4 Potential Savings .......................................................................................................................... 5 Recommendation 3 – Expand “Do Not Pay List” .......................................................................... 5 Potential Savings .......................................................................................................................... 6 Recommendation 4 – Publicize Drug Expiration Dates ................................................................ 6 Potential Savings ....................................................................
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...MARKETING PLAN FOR ABIGAIL’S MEDICAL BILLING AND CODING Abigail’s Medical Billing and Coding Services, LLC is an accurate, timely and affordabl Here are the major elements of a marketing plan: Executive Summary: The Executive Summary should be a brief summary of the entire marketing plan and include the highlights of each section to be included in your marketing plan. It should also include your Business's Mission (or Vision) Statement. Start with your Mission Statement and use this as a foundation for the rest of marketing plan. Next, work on the rest of the plan, skipping the remainder of this section until the rest of the marketing plan is complete. Your Mission Statement should be a simple paragraph describing your company's values as well as what your company does and who it is. After the rest of the marketing plan is complete, come back and finish the Executive Summary. Product Description: The product description is the detailed description of the products and/or services that you intend to market. Anywhere in length from a few paragraphs to a few pages, use this as an opportunity to communicate your ideas regarding exactly what your product is and how your customers will use it. Market Analysis: The Market Analysis is drawn from in-house or third party Marketing Research and includes: * A description of the target market * Distribution channels with any applicable laws or regulations * The unique positioning of the company and its products...
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...Compliance and Coding Management Task 2 Western Governor’s University Compliance and Coding Management Task 2 A. Outline a HIM compliance plan that emphasizes the coding function by doing the following: 1. The necessary components of a compliance plan include Code of conduct, policies and procedures, education and training, communication, auditing, corrective action and reporting. The code of conduct is a statement or oath that establishes the intent to perform duties lawfully and ethically. The second component of a plan would include policies and procedures. The policies and procedures for coding would cover items such as how and when to query a physician, acceptable documentation sources, how to rebill a claim, usage of coding guidelines, payer specific issues, and any additional gray areas that may arise in the coding function. Education and training processes must also be outlined in a HIM compliance plan. This would need to identify the number of mandatory CEU’s for each employee, new hire training guidance and requirements, as well as physician and clinical staff educational guidelines and processes. The HIM/Coding compliance plan should also include policies and procedures that address communication, the auditing/monitoring process, any necessary corrective action steps and finally the process for reporting the coding compliance steps that have been followed and any areas identified as risks or any findings of noncompliance. 2. The HIM director...
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...element of this situation is that recent cases have shown that medical professionals are more willing to risk patient harm in pursuit of successfully executing their schemes. Health Care fraud is in the jurisdiction of the FBI. They are the primary agency responsible for investigating these types of cases, and also for exposing them. They are responsible for the federal and private insurance programs. As the Chief Medical Officer of a large Obstetrics Health Care Center, I am sadden and extremely angry to learn that these types of fraudulent activities are associated with my facility. As I investigate and learn more about the situation, I will also be exploring other topics as listed below. 1. Evaluate how the Healthcare Qui Tam affects health care organizations. 2. Provide four (4) examples of Qui Tam cases that exist in a variety of health care organizations. 3. Devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals. 4. Recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will...
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...Medicare Fraud: The History, Incidence, Costs and Institutional Remedies John H Everett Wayland Baptist Medicare Fraud: The History, Incidence, Costs and Institutional Remedies What is Medicare fraud? ("F&A," 2011, p. 1) states “Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year.” What is Medicare abuse? ("F&A," 2011, p. 1) defines this as “Abuse occurs when doctors or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.” In reviewing the definitions of fraud and abuse by Medicare it may be hard for some people to understand if they do not live in the healthcare world daily. In an effort to help shed some light on this, we will look at the history of Medicare fraud. It has been around since the Civil War, when the False Claims Act (FCA) was created. It was also called the Qui Tam Statue meaning “he who sues for the king as himself.” ("FCA," 2011, p. 1) “The law was targeted at stopping dishonest suppliers to the military Union military at a time when the war effort made it all but impossible for the government to investigate and prosecute the fraud itself. Today it serves a similar purpose because of the enormous size of the federal government and the variety or programs under which it expends taxpayer funds.” In 1986 the FCA has been revised over the...
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...Healthcare Fraud and Abuse Under HIPPA, “fraud is defined as knowingly, and willfully executes or attempts to execute a scheme… to defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses, representations, or promises any of the money or property owned by…any healthcare benefit.” Unlike Fraud, abuse is, “means that are improper, inappropriate, outside of acceptable standards of professional conduct or medically unnecessary.” Health care fraud arises from an individual or group of individuals filing of a dishonest health care claim in order to turn it into a profit. Abuse; however, is harder for the investigator to identify and establish if the act was committed knowingly, willfully, and intentionally. Healthcare industry is one of the fastest growing sectors of the US economy; almost 10% of the US’s national GDP is consumed by the health care industry. According to Forbes’s report, the US National Healthcare expenditure of 2012 was nearly $3 Trillion. According to the National Healthcare Anti-Fraud Association, nearly $60 Billion is lost to healthcare fraud each year. The healthcare industry is an enormous market; therefore, making it easier for healthcare providers to take advantage of the American population. This paper will focus on why fraud and abuse occurs, different types of fraud, example cases of fraud and abuse, impact to present day healthcare industry, and potential solutions to fixing and preventing fraud and abuse from occurring...
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...organizations vision and formulated goals. Arcade General Hospital is in the third stage of upgrading a clinical information system and their goal is to integrate the new upgrades with the application of meaningful use through adherence to the American Recovery and Reinvestment Act (ARRA) by promoting the adoption and meaningful use of health information technology. Usability in is one of the main goals as it will allow minimal disruption in clinical workflow. Meaningful Use In 2009, the American Recovery and Reinvestment Act (ARRA) and the Centers for Medicare & Medicaid Services (CMS) released a rule on payment incentives for meaning use of clinical information systems (CIS). This rule was designed to entice hospitals and medical clinics to qualify for payments incentives if they adopted the necessary requirement in association with the progression of electronic medical record (EMR) implementation (American Hospital Association, n.d.). The use of meaningful use will include the ability for clinicians to access information to provide best of care for patients, better access to clinical information and for patients to receive ability to play a more active role having access to the private medical information. As per the ARRA incentive program, AGH has upgraded and implemented their CIS and has Certification...
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