Recovery Audit Program Extended to Medicaid

White House pushes to further curb waste, fraud and abuse…
Last week the Department of Health and Human Services (HHS) released its final rule establishing the Medicaid Recovery Audit program.  The Centers for Medicare and Medicaid Services (CMS) touted the program as a key part of the Obama Administration’s initiatives to curb waste, fraud and abuse within the Medicaid system, and extending the Recovery Audit initiatives beyond Medicare for the first time.

Affordable Care Act Expands
Once again, we see the “Obamacare” Act, formally the Affordable Care Act, further taking shape and reaching out to touch yet another entitlement program.  The program was introduced by CMS and places even more powers in the hands of Recovery Audit Contractors (RAC’s) by giving them the ability to detect and correct past improper payments, and review claims after Medicaid payments have been made.  Automated and detailed review protocols will be implemented that include medical records reviews of all types, including ambulance.  RAC’s will be given the ability to review claims dating back three years from the date the claim was paid and they will be charged with identifying and recovering over and under (more over than under we’re sure) payments to providers in the Medicaid system.

The Cost – $350 Million Over 10 Years!
“The Affordable Care Act provides an additional $350 million over the next 10 years and an annual inflation adjustment to ramp up anti-fraud efforts, including increasing scrutiny of claims before they’ve been paid, investments in sophisticated data analytics and more ‘feet on the street’ law enforcement agents and others to fight fraud in the health care system,” says CMS in a recent Fee-For-Service listserv e-mail.  However with projected savings estimated to possibly hit the $2 billion mark, the Administration is betting that the system will more than recover those fees over time.

The e-mail announcement explains that CMS intends to use similar technology used by credit card companies to stop fraud. 

How Should EMS Organizations Prepare?

We recommend these few steps to take in preparation for a potential audit.

First, DOCUMENT, DOCUMENT, DOCUMENT!!  Invest in documentation training and re-training for your staff both now and in the future.  If you outsource your billing, your billing contractor should help you locate resources, both written and human, to help you with this task.  Enhanced supports all of our clients with in-person documentation training during the initial boarding process and afterwards we provide support when and where it’s needed for all of our clients.

Next, review your call intake processes.  Are your call-takers verifying medical necessity?  Are your crew members adequately educated about the basic rules and regulations and are they empowered to question a patient’s medical necessity in the field for all ambulance transports?  Have you, the administrator, provided a process for such questioning and field-driven feedback?

Most importantly, be sure that your billing contractor or in-house billing staff only employs hands-on billing staff that are Certified Ambulance Coder™  trained.  Specific to the ambulance industry, the National Academy of Ambulance Coding’s CAC™ curriculum is the most comprehensive program available today.  Here at Enhanced, we were the first all-EMS billing company in the United States to commit to having all of our billing staff attain Certified Ambulance Coder™ certification status.  Our commitment to all things compliance drives every Enhanced process.

Finally, develop a written, working compliance plan.  There are a number of resources available to help your organization put this plan of action in place.  You have SOP’s for everything else you do….then why not have this in place as well?  And…don’t just place the plan on a shelf somewhere once it’s written.  Follow it.  Review it.  Educate your staff at every level of its importance to the growth, stability and integrity of your EMS organization.

Are you ready?
At some point an audit request will arrive in your mailbox.  Are you ready?  Ask that question now and don’t finish asking until you have an answer that allows you to sleep at night.  If your questions go unanswered just pick up the phone and give Enhanced a call.  We’ll help you pinpoint areas of concern and establish a billing program for you that will keep you off the RAC radar.

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