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Unnecessary Procedures on Cutting Block for CMS Reimbursement
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Starting Jan. 1, the CMS began demonstration programs intended to eliminate fraud, waste and abuse in an attempt to strengthen Medicare.
Following in the wake of the recent high publicity cases of over-stenting, the Recovery Audit Prepayment Review demonstration will allow Medicare auditors to review claims before paying them and will ensure provider compliance with payment rules. Auditors will conduct repayment reviews on claims with a historically high rate of improper payments and will focus these reviews on states with high populations of fraud- and error-prone providers (California, Florida, Illinois, Louisiana, Michigan, New York and Texas), as well as states with high claims volumes of short inpatient hospital stays (Missouri, North Carolina, Ohio and Pennsylvania), according to a press release issued by CMS.
A second demonstration, the Prior Authorization for Certain Medical Equipment, will necessitate prior authorization of certain medical equipment for Medicare participants residing in the seven states with high numbers of fraud- and error-prone providers. This will be implemented in two phases, the release stated. During the first phase, which spans the first 3 to 9 months, Medicare contractors will conduct prepayment reviews on certain medical equipment claims; for the second phase, which takes place over the remainder of the 3-year demonstration, prior authorization, which is used by private-sector health care payers to prevent improper payments and deter fraudulent provision of items or services, will be implemented.
CMS has also announced that a third initiative, which will be limited to a representative sample of 380 nationwide hospitals that volunteer, will allow hospitals to rebill for 90% of the Part B payment when a Medicare contractor denies a Part A inpatient short stay claim as not reasonable and necessary due to the hospital billing for the wrong setting. Presently, the entire claim is denied in full when outpatient services are billed as inpatient services.