Tag: RAC audits

Vyne Medical Launches Refyne, a SaaS Platform To Facilitate Electronic Submission of Medicare Audit Responses

Vyne Medical today announced the launch of its new Refyne platform. Purpose built for healthcare, Refyne is designed with the look and feel of a modern consumer-facing app and features to help optimize administrative workflows and maximize reimbursements for hospitals and health systems.

This initial release of the cloud-based platform features Refyne Audits which simplifies the process of receiving and responding to audit requests from the Centers for Medicare & Medicaid Services (CMS). In fiscal year 2020, CMS estimated the improper payment rate for Medicare fee-for-service at 6.27 percent, representing $25.74 billion in improper payments.

“Our nearly 10 years of experience as a leading CMS-Certified Health Information Handler tells us that managing government audits plays a significant role in effective denials management.” said Marcy Tatsch, president of Vyne Medical. “That experience coupled with the Refyne Audits solution enables us to add immediate value for both new and existing clients.”

Refyne Audits facilitates the electronic transmission of supporting documentation to assist providers in filing timely audit responses and appeals. The solution enables participation in the CMS Electronic Submission of Medical Documentation (esMD) initiative with the Electronic Medical Documentation Request (eMDR) functionality necessary for efficient audit management.

“With Refyne Audits, providers can automate workflows and supply the solicited evidence necessary to fight government audits well within strict timelines,” said Scott Overholt, chief business officer at Vyne Medical. “Hospitals can quickly submit hundreds of pages of documentation to demonstrate appropriate levels of care and most importantly, they can track their submissions to prove timely responses.”

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CMS Proposes Extension of RAC Audit to Medicare Advantage Plans

Guest post by Rajeev Rajagopal, president, Outsource Strategies.

Rajeev Rajagopal
Rajeev Rajagopal

The proposal of the Centers for Medicare & Medicaid Services (CMS) to expand its Recovery Audit Program to Medicare Part C or Medicare Advantage (MA) plans is a new step in its efforts to fight fraud, waste and abuse in the Medicare program. The move is aimed at identifying overpayments and underpayments made on claims for services provided to Medicare beneficiaries. For physicians’ practices, the expanded recovery audit program would mean that they will have to take proactive steps to reduce their risks of falling prey to recovery audits by pay ensuring error-free submission of the claims of MA patients.  Outsourcing medical billing and coding is a great option to accomplish this task.

Medicare Advantage (MA) Plans and Allegations of Billing Fraud

MA plans or Medicare Part C are offered by private insurance companies approved by Medicare, which receive payment from Medicare for the coverage provided. There are different types of MA plans which provide all of a Medicare patient’s Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Part C plans are different from standard Medicare in that they are paid a set fee every month for each patient based on a complex formula called a risk score. CMS pays higher rates for sicker MA beneficiaries than for those in good health. CMS scrutinizes the diagnosis information reported by MA organizations and calculates risk scores for each enrollee using the Hierarchical Condition Category risk adjustment model. The risk score is calculated based on the enrollee’s demographic characteristics and health conditions. This practice aims to improve the accuracy of Medicare’s payments to MA organizations and reduces the incentives for plans to select only the healthiest beneficiaries.

Identifying Improper Medicare Payments with Recovery Audits

However, in recent years, there have been various reports of overbilling MA plans, costing taxpayers billions of dollars more than warranted. In Jan. 1, 2010, the government set up the Recovery Audit Program to fight fraud, waste and abuse in the Medicare program. It detects overpayments and underpayments for Medicare claims so that CMS can implement actions to prevent improper payments in all 50 states. Under the program, Recovery Audit Contractors (RACs) — private companies hired by CMS — have the authority to review medical records at short notice. RACs notify health care providers of the outcomes of the reviews via demand letters. An RAC demand letter would contain details of the problem with a claim, such as the coverage, coding or payment policy that was violated, a description of the overpayment made, recommended corrective actions, and explanations on the provider’s right to submit a rebuttal statement prior to recoupment of any overpayment and appeal and more.

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RAC Audits: Surviving the Inquisition

Michael Murphy, MD
Michael Murphy, MD

Guest post by Michael Murphy, MD, co-founder and CEO, Scribe America.

In May 2014, the Department of Health and Human Services released findings of their most recent study pertaining to reimbursement amounts provided to outpatient physicians for evaluation and management services. The study uncovered that Medicare overpaid outpatient physicians close to $7 billion and most improper payments were results of errors in coding and insufficient documentation (Table 1, highlights the percentage of claims that were wrongfully claimed for in 2010.). However this is not a problem isolated to physicians from the outpatient clinics, as physicians from inpatient clinics could also be found guilty of miscoding and insufficient documentation.

Recovery audit contractors (RACs) were created by the Medicare Modernization Act to evaluate the accuracy of Medicare claims. If a claim is determined by RAC to be flawed for any one of the many different reasons, the claim is denied. Although Medicare’s retrospective program of auditing bills is good, it is not perfect. There has been a huge spike in appeals of Medicare payment decisions, from hospitals mainly, since the introduction of the auditing program and delays in the appeal process has resulted in hospitals facing great financial difficulties as a lot of their funds are tied up till the appeal has been heard.

Type of ErrorPercentage of Claims for outpatient servicesMedicare Payments (in Billions)
Incorrectly Coded42.4%$3.3
-Miscoded40.4%$2.8
-Upcoded26.0%$4.6
-Downcoded14.5%($1.8)
-Other Coding Error (e.g., Wrong Code, Unbundling)2.0%$0.5
Lacking Documentation19.0%$4.6
-Insufficiently Documented12.0%$2.6
-Undocumented7.0%$2.0
Overall Gross61.3%$7.9
Overlapping(6.7%)$2.0
Overall Net54.6%$6.7

Adapted from : “Improper payments for evaluation and management services cost medicare billions in 2010”

In order to receive reimbursement from Medicare, a physician needs to follow a three-step process: 1) appropriate coding of the service provided by utilising current procedural terminology (CPT); 2) appropriate coding of the diagnosis using ICD-9 code; and 3) the Centers for Medicare and Medicaid Services (CMS) determination of the appropriate fee based on the resources-based relative value scale (RBRVS). It is not surprising that physicians often incorrectly code patient visits and procedures as there exists a truly daunting number of codes from which to choose. Moreover, coding structure and reimbursements schemes are constantly evolving and becoming more complex, resulting in a coding process that is often cumbersome and difficult.

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