Recovery Audit Contractors (RACs) “are bounty hunters,” she said. They are focused on recovering misspent Medicare funds and are paid a contingency fee of 9%–12% of the amount recovered. However, they are not active in practices because they have enjoyed such success in hospitals. At present, they do automated screening of practices’ Part B payments. “If you fall out of the screen, they ask for the money back and that’s the end,” Ms. Buell said. She cautioned, however, that RACs might start doing complex reviews later this year. And if they do, drugs are likely to be an early focus “because there is so much money involved and they have seen that [in the hospitals].”
Medicaid Integrity Contractors (MICs) review Medicaid claims for inappropriate payments and fraud, using a data-driven approach to identify aberrant billing practices. Unlike RACs, who receive a contingency fee, MICs are paid for their services and receive a quality-related bonus. Their look-back period for medical records varies by state. At present, they target mainly hospitals and, to a lesser extent, skilled nursing facilities, nursing homes, and hospices. Physicians are low on the list of priorities, “but…if you have a heavy Medicaid load, you do have to worry about [it],” Ms. Buell said.
Medicare Administrative Contractors (MACs) process claims for both Part A and Part B services and therefore can review discrepancies between the two sets of claims, revise payments, and increase denials. Some ongoing MAC activities include audits regarding usage of the 99204 and 99205 procedure codes for new patients.
Minimizing the risks
Given this environment, what can oncology practices do to minimize their risk? “Have a compliance [program] and make it a priority,” Ms. Buell recommended, adding that it is also a requirement of healthcare reform. Be sure to fix anything the program identifies, because auditors will take a much stiffer stance if they discover issues that were known but not resolved.
Practices can refer to a set of components that the OIG has set forth as the foundation of an effective compliance and ethics program (www.oig.hhs.gov/authorities/docs/physician.pdf). For example, there should be standard policies and procedures in the practice for things such as documentation, education and training, and updates on Medicare regulations. The enforcement of these policies is also a key element of an effective compliance program, as is a prevention component that anticipates mistakes and prevents them from occurring whenever possible.
The healthcare reform legislation requires that practices report and return Medicare and Medicaid overpayments. “If you find that you have been overpaid, for any reason, even if it’s their mistake, give the money back,” Ms. Buell said, because there is a good chance that auditors will eventually discover it.
Any practice that is concerned about being at risk for whistle-blower incidents should obtain legal help. “If you think there is…someone out there who can hurt you, you need to have your compliance program administered by an attorney.”
Finally, “educate, educate, educate,” she advised, to keep physicians and other practice members current on compliance issues.