Health System Reform Insight - May 24, 2012
Given the new direction for the nation's health system, the AMA has developed Health System Reform Insight to help you understand what this new direction means to you and your patients.
Federal lawmakers on both sides of the aisle agree: Waste, fraud and abuse must be eradicated from federal health care programs. The AMA supports efforts to identify true fraud and abuse but recognizes that the federal government's program integrity efforts frequently result in a substantial administrative burden for physician practices. The AMA is committed to addressing physicians' legitimate concerns about these programs.
Some of the AMA's notable achievements to ensure that physicians are not overwhelmed with audits and bureaucratic hurdles are summarized below.
Physicians who undergo audits face tremendous expense and administrative requirements. Recent improvements to the Medicare Recovery Audit Contractor (RAC) program include a limit of 10 medical record requests within 45 days to small physician practices, a lost fee if the review is not completed within 60 days and a "discussion period" during which physicians may speak with a RAC medical director about an audit.
Recent improvements to the Medicaid RAC program include a three-year limit on the look-back period, restrictions on the number and frequency of medical record requests, and a requirement that RACs hire medical directors and certified coders. States also must adequately incentivize RACs to identify underpayments and coordinate with other audit contractors to avoid redundant efforts.
Following the AMA's argument that post-payment RACs have a poor performance record and are not equipped to review claims before they are paid, CMS has twice delayed the RAC prepayment demonstration. The program has not yet launched.
Finally, CMS has begun auditing its audit programs to potentially reduce the number of duplicative and onerous audits physicians face.
Medicare enrollment and revalidation
CMS made sweeping improvements to the online Medicare Provider Enrollment, Chain and Ownership System (PECOS), including the ability to submit e-signatures and upload electronic documents. After the AMA expressed concern about CMS's legal authority to revalidate all physician enrollment by 2013, CMS extended the revalidation effort through 2015.
CMS also responded to AMA concerns about the workflow problems and potential claim rejections that ordering and referring physicians would face if they were required to enroll in Medicare via PECOS. Referrals to physician specialists are now excluded from this requirement, among other key improvements.
Physicians who participate in Medicare now are subject to risk-based screening when they enroll or revalidate enrollment. Following the AMA's assertion that physicians are of low risk, CMS only subjects physicians to the least burdensome screening requirements.
Identify theft and fraudulent activity
CMS created a new streamlined process for investigating and restoring the financial integrity of physicians who are victims of identity theft. The agency also has designated an ombudsman at each contractor to assist physicians who have been victims of identity theft.
CMS's new data analytics program to identify fraudulent activity in a targeted manner established the following guidelines to protect honest physicians, based on AMA recommendations:
- Prompt payment will be waived only in exceptional and urgent circumstances.
- Clinical experts across the country and of every specialty will work with CMS on claims review.
- CMS is not denying claims based solely on the program and will develop models that do not disrupt claims processing.
The AMA also secured broad waivers of such program integrity laws as an anti-kickback law and a physician self-referral law that may inappropriately apply to innovative payment and delivery arrangements, including the Medicare accountable care organization program. These waivers should allow more physicians to participate in health care innovations.
AMA members can influence AMA policy by voicing their views about reports and resolutions submitted for the Annual Meeting of the AMA House of Delegates in a secure online forum (AMA login required). Comments and testimony will be accepted until 6 p.m. Central time on this date.
Physicians have until this date to report on at least 10 electronic scripts, known as e-scripts, or file a hardship exemption to avoid a 1.5 percent reduction in Medicare Part B payments in 2013. View an AMA tip sheet to learn more.
Physicians must be in compliance with standards for the Health Insurance Portability and Accountability Act version 5010 electronic transactions by this date. Physicians who continue to experience difficulties with claims processing should complete a complaint form.