• Recovery Audit Contractor Overview
• AAOS Worth Repeating: Are You An E&M Outlier?
• Featured Legislator: US Representative Gene Green (29th District)
• This Week In Texas: Mignon McGarry Memos
• Save The Date: 2010 TOA Socioeconomic Summit

• Save The Date: 2010 TOA Annual Meeting

 
Recovery Audit Contractor Overview
  

By John Early, MD President, Texas Orthopaedic Association     One of our very astute TOA Board members is pointing out concerns we may need to address in 2010 with the CMS RACs. Dr. Patrick Palmer (AAOS Board of Councilor from Texas) and Dr. Christian Royer (TOA Representative to Trailblazer) are teaming up to monitor some of the issues expected to hit orthopaedic surgeons in Texas next year.

You may already be aware of the Recovery Auditor Contractors working with the Center for Medicare and Medicaid Services, but here is some background information and a link to CMS that may be of interest.

Overview

On February 28, 2008, the Center for Medicare and Medicaid Services (CMS) released the Medicare recovery audit contractor (RAC) status document and press release for the fiscal year of 2007. The RAC demonstration project has operated since 2005 in the states of California, New York, and Florida. The demonstration project was to determine whether RACs would be a cost-effective means of identifying Medicare underpayments and overpayments, and mainly focus on recovering the overpayments.

RACs supposedly identified and corrected $371.5 million in improper Medicare payments during 2007 (at a cost of $77.7 million, returning $247.4 million to the Medicare Trust Fund.  Only 4 percent (14.3 million) of the improper payments identified during 2007 were underpayments repaid to providers.

In 2008, CMS reported recovery of more than $1 billion through the RAC pilot program, and that 96 percent of the recovered funds were from overpayments to providers. By January 2010, CMS plans to have four RACs in place to audit Medicare payments in all states. The RAC is now a permanent national program.

Since RACs are paid on a contingency fee basis, they receive a portion of the money recovered from providers. This means this will be a risk-free process for CMS. Future audits will be, no doubt, more aggressive than the CMS audit programs of the past.

Proprietary data mining software will be used by RACs to identify claim errors. Healthcare providers will have 60 days to reconcile RAC findings and refund Medicare payments. This RAC program will create a variety of administrative burdens, compliance issues, and cash flow concerns for healthcare providers. Healthcare providers will see these items questioned as a result of the RAC pilot program:
 

TOA is researching companies who may wish to partner with us on pre-RAC audit risk and liability on claims already processed and paid by Medicare. Whether each orthopaedist has the in-house talent to do their own internal pre-audit or if an outside company will assist, orthopaedic practices will want to:

• ensure that claims are properly coded in accordance with Medicare rules and regulations

• identify procedure-to-diagnosis mismatches, unbundling occurrences, nonspecific diagnosis codes, global service violations, potential unbilled revenue

• any other problem areas which could be targeted by RAC audits

• assess their own audit risks after writing rules sets based on their internal audit findings.

CMS guidelines will continue to grow more complex due to the Medicare RAC program. It will be very important to stay compliant with the rapidly changing rules and regulations.

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AAOS Worth Repeating: Are You An E&M Outlier?
    

By Mary LeGrand, RN, MA, CCS-P, CPC, and M. Bradford Henley, MD, MBA Benchmarking yourself can show variations in practice patterns

No orthopaedic practice wants to become the subject of a billing audit by the Office of the Inspector General (OIG) or a Medicare Recovery Audit Contractor (RAC). But certain office procedures—such as how you schedule and code postoperative visits that occur immediately after the end of the global billing period and how well you adhere to the Medicare Global Surgical Package rules associated with the reporting of "related" postoperative problems—can increase your risk of such an audit. (See "Check your schedule for an audit time bomb," July 2009 AAOS Now.) As you review your procedures to ensure that you are properly coding such visits, take some extra time to examine the frequency of your evaluation and management (E&M) code usage. Are the levels of service you report for new, established, and consultation services dramatically different from those reported by your partners and other orthopaedic surgeons? Comparing each doctor in a group to the state or national Medicare data is a way to see if your code usage is a flashing yellow light for auditors. By taking the time to analyze your E&M services coding, you'll find out whether your coding marks you as an outlier and whether the documentation you have supports the codes you claim. See the full article in the AAOS Now August 2009 online publication here. [top] [back to e-card archive page]

Featured Legislator: US Representative Gene Green (29th District)

This Week In Texas: Mignon McGarry Memos
      

By Mignon McGarry TOA Legislative Advocate TOA Online Version: All Memos   August 26, 2009, Wednesday Gov. Rick Perry has appointed Carlos Rubinstein of Austin to the Texas Commission on Environmental Quality effective Aug. 31, 2009, for a term

to expire Aug. 31, 2015, and appointed Bryan W. Shaw, Ph.D., of Round Rock as presiding officer of the commission effective Sept. 10, 2009. TCEQ oversees and establishes policy for the state's lead environmental permitting and enforcement agency. Texas House Speaker Joe Straus's communications director Angela Hale announced her departure from the Speaker's office to join Red Media Group as managing partner. Red Media Group is a strategic communications company with offices in Austin and Dallas. Many of the new laws passed by the Texas Legislature this past spring will take effect next week on September 1st.  643 bills to be exact.  The entire list can be found here. Here are two that will likely affect most Texans: House Bill 537 requires all vehicle occupants to wear a safety belt regardless of age or where they are seated in the vehicle.  That means you backseat drivers have to buckle up.  The bill also raises the age limit for booster seats from 5 years old to 8 years old or at least 4 feet, 9 inches in height.  The booster seat provision will not be enforced until June of 2010 in order to allow time for parents to comply. House Bill 55 prohibits the use of cell phones while driving in school zones unless the vehicle is stopped or making an emergency call. However, local governments are supposed to post signs at the beginning of each school zone to inform drivers of the new law in order to enforce it.  With many local governments already cutting their budgets, expect these signs to go up very slowly. [top] [back to e-card archive page]

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