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Just because the Medicare payment error rate is down and more provider-friendly Republicans are running the White House, that doesn’t mean federal auditors will be going away.
Acknowledging that compliance efforts of the Office of Inspector General and Health Care Financing Administration (HCFA) have had a major impact on reducing payment errors, "problems remain in ensuring providers maintain adequate documentation, properly code claims, and bill only for services that are medically necessary," maintains Acting Inspector General Michael F. Mangano. "Continued vigilance is needed to allow HCFA to sustain and build on this progress."
"HCFA has made significant improvement toward assuring proper payment for medical services, but more must be done," adds Health and Human Services Secretary Tommy Thompson.
But there may be some good news from inside the Beltway. President Bush’s proposed 2002 federal budget includes some $156 billion to reform Medicare and the Health Care Financing Administration. As part of the GOP’s more "provider friendly" approach to regulatory issues, this first Bush budget takes HCFA to task, calling for much-needed management reforms within the agency.
"The Medicare program, with ever-increasing pages of regulations, administrative guidelines and other endless directives issued on a monthly basis, leaves providers and beneficiaries often bewildered and frustrated," according to language in the proposed budget.
"We must not only modernize Medicare’s accounting systems, but also make its rules and procedures more understandable and user-friendly," Secretary Thompson recently noted. "If we can make our programs and our coverage easier to understand, we’ll be helping physicians and other providers to avoid unintended errors, and we’ll help detect deliberate abuses as well."
That’s the good news. The other news is that Bush wants to institute a $1.50 fee on all Medicare claims not submitted electronically and on claims that are duplicates or cannot be processed. This would help pay for HCFA’s management makeover.
Because President Bush is a middle-of-the-road GOP politician who has cast himself as a "compassionate conservative," he may attempt to reform Medicare and how HCFA manages the program without being perceived as being soft on "waste, fraud and abuse." Therefore, it is just as much in his interest to keep lowering HCFA’s reimbursement error rate as it was in the interest of his presidential predecessor.
One way the administration means to do this is by asking for $700 million in FY 2002 (a $20 million increase) to run HCFA’s Medicare Integrity Program. This program is designed to pay particular attention to pre-payment claim reviews intended to stop improper payments before Medicare cuts a check, rather than trying to collect an overpayment afterward.
With the added emphasis on prepayment reviews, a good way to avoid getting your claim bumped back to you is to make sure each bill undergoes the same basic check for obvious errors that government computers look for in their first-level edits before your bill is sent to Medicare. Items these initial pre-payment edits look for include:
Additionally, HCFA will employ these initiatives in an attempt to continue to cut Medicare’s improper payment rate over the next year:
— Target program vulnerabilities. Since 1999, HCFA has used special contractors with program integrity experience to target problem areas, such as reviewing claims for therapy services and developing data analysis centers to identify and stop payment errors and possible fraud.
— Develop contractor-specific error rates. Last year, HCFA began developing error rates for each of the private insurance companies that pay Medicare claims to better target their education and program integrity efforts. These new measures are expected to prompt contractors to more closely scrutinize claims to avoid high erroneous payment profiles. The first contractor-specific rates are expected in 2002.
— Improve customer service. As part of the "kinder and gentler" HCFA, the agency is expanding efforts to improve the customer service provided by claims-processing contractors to ensure that they provide accurate, reliable, and relevant information about Medicare coverage and billing to physicians.
— Expand education and outreach. HCFA will continue to expand its education efforts to help doctors, hospitals, and other providers learn how to properly file and document claims. HCFA already provides free information, educational courses, and other services on the Web through the Medicare Learning Network at www.hcfa.gov/ medlearn.
— Clarify documentation guidelines. This year, HCFA will test new guidelines for physicians who provide evaluation and management services to patients. The guidelines are designed to ensure Medicare pays claims appropriately while minimizing the paperwork burden for doctors.
— Tighten provider enrollment review. Look for HCFA to issue new procedures designed to help spot unqualified providers and prevent them from getting into the Medicare program in the first place, which in turn will reduce bogus billing schemes.
One new wrinkle to beware of was mentioned by Gail Kursh, head of the Justice Department’s Health Law Section, at a recent meeting of the American Bar Association. Kursh told the meeting that the department is taking a closer look at antitrust issues inherent in "over-inclusive" groups of providers or individual physicians that are not clinically integrated in some manner but who work together to negotiate managed care contracts. "This is conduct that raises serious concerns within the division, and we will continue to scrutinize it carefully," she said.
Another priority area of investigation at the Justice Department is the continuing consolidation among managed care plans and HMOs and the effect this has had on the power of a plan to suppress physician prices.