1 / 22

RAC Update GAHA: 2014 Health Care Law Update May 16, 2014

RAC Update GAHA: 2014 Health Care Law Update May 16, 2014. Tracy M. Field, M.S., J.D. Womble Carlyle Sandridge & Rice, LLP 271 17 th Street, NW – Suite 2400, Atlanta, GA 30363 (404) 962-7539. MEDICARE AUDITS Now What?. Perspective: By challenging denials, CMS changed the rules!

roddy
Download Presentation

RAC Update GAHA: 2014 Health Care Law Update May 16, 2014

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. RAC UpdateGAHA: 2014 Health Care Law UpdateMay 16, 2014 • Tracy M. Field, M.S., J.D. • Womble Carlyle Sandridge & Rice, LLP • 271 17th Street, NW – Suite 2400, Atlanta, GA 30363 • (404) 962-7539

  2. MEDICARE AUDITSNow What? • Perspective: • By challenging denials, CMS changed the rules! • Compliance challenge: How assess accuracy? • Business reasons for rebilling Part B • 2 year backlog – and growing!

  3. ALJ BACKLOGOMHA February 2014 Forum Office of Medicare Hearings and Appeals (OMHA) Forum: February 12, 2014 • Backlog of 500,000 cases – and counting! • Moratorium on docketing new appeals until workload addressed per ALJ • Hearings being scheduled

  4. ALJ BACKLOGOMHA February 2014 Forum • Backlog • Budget increase: 18+% (after sequester) • Statistical sampling? • OMHA statistician • Appropriate for fact-specific cases • Mediation/Alternative Dispute Resolution • New regulations

  5. ALJ BACKLOGOMHA February 2014 Forum • No longer need to submit medical records? • Group cases – but individually file! • Electronic filing? • Send files via tracking methods, and don’t expect an acknowledgment! • Miami pilot • 2 year development from award

  6. ALJ BACKLOGOMHA February 2014 Forum • Backlog • Increase in Escalation to DAB-MAC • NO Hearing at DAB-MAC • Access to federal court sooner – but… • OMHA stated testimony makes difference - yet • OMHA suggested may not want to request hearing?

  7. ALJ BACKLOGOMHA February 2014 Forum • Legal Considerations • Medicare Modernization Act (MMA) and BIPA deadlines not being met • For medical necessity cases, what standard of review applies? • Confusion on effective dates for local coverage determinations (LCDs) • Jimmo Case: Important for rehab, other uses?

  8. ALJ BACKLOGOMHA February 2014 Forum • Compliance Considerations • Part A/B Claims: 97% of appeals • Redetermination reversal rate to fully favorable: • 30% per OMHA

  9. ALJ BACKLOGOMHA February 2014 Forum For OMHA Outcomes of Cases Decided at ALJ • 37% Fully Favorable – 4% Partially Favorable • 30% Unfavorable • 1% Remand • 27% Dismissed Impact on Compliance activities….

  10. RAC REPORT(March) 2014 For FYE 2012: • Increasing RAC Activity • Medicaid RACs • Data warehouse • Validation audits, education • “Maximize transparency” • Hearing Participation

  11. RAC REPORT(March) 2014 For FYE 2012: • Collected $2.3 Billion in overpayments… • New initiatives to prevent provider appeals? • The 2 Midnight Rule • Subregulatory Guidance?

  12. MAC REVIEWS • RAC Denial •  • Redetermination (MAC) •  • Qualified Independent Contractor (QIC) •  • Administrative Law Judge (ALJ) •  • Medicare Appeals Council (MAC)/Departmental Appeals Board (DAB) •  • Federal Court

  13. INITIAL REVIEWSProbe Audits • MAC Audits: January 2014 • MAC prepayment reviews: “probe and educate” • Recovery Audits: • Delayed until November 2014 – but the probe audits continue….

  14. INITIAL REVIEWSProbe Audits • Presumptions that Hospital Stays Less than 2 Midnights are Not Medically Necessary • Presumption does not mean wrong!! • Legal challenges to denials • Strategy to avoid audits • Some opted for no one-day stays • Rebill under Part B?

  15. MEDICARE APPEALSOther Considerations • IPPS Proposed Rule: Payment for Short Stay Admissions: • Payment under OPPS or IPPS? • AHA Litigation: • Challenges the 2 Midnight Rule; Part A/B Rebilling time limitations and physician certification of orders as payment condition

  16. REFERENCES www.hhs.gov/omha • Per OMHA: Updates after 15th of each month on adjudication timelines, processes • OMHA Adjudication Manual Pending

  17. QUESTIONS? Tracy M. Field, M.S., J.D. tfield@wscr.com (404) 962-7539 Womble Carlyle Sandridge & Rice, LLP 271 17th Street, N.W. Suite 2400 Atlanta, Georgia 30363

More Related