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The retrospective audit is becoming an increasingly attractive method for payers to determine overpayments and recoup money. For example, the American Hospital Association’s RACTrac survey reveals that the number of RAC medical record requests increased by more than 50 percent from third quarter 2012 to first quarter 2013, and the total number of complex audit denials increased by 42 percent during the same period.
This is a sample article from HFMA's Payment & Reimbursement Forum, a networking and discussion community for managed care, reimbursement, and other healthcare finance leaders.
Learn more about the P&R Forum
Although less common than RAC audits, retrospective audits by commercial payers are also increasing. Commercial payer audits may occur separately from a RAC audit or dovetail with the federal government’s efforts. Recently, for example, several commercial payers “piggybacked” on a Medicare audit of a Kansas physician group, seeking to recoup perceived secondary insurance overpayments associated with the Medicare audit before the physician group had a chance to appeal, according to a Health Business Daily article. In the following Q&A, Richard Quadrino, founding partner of the New York law firm Quadrino Schwartz, shares some insights on commercial recoupments as well as some ideas on how healthcare organizations can prevent retrospective audits. Do commercial payers often seek recoupment from healthcare organizations?Quadrino: Although they don’t happen as frequently as RAC audits, I am seeing an increase in commercial audits and recoupments, reflecting a national trend. Commercial audits can target a variety of providers. For example, I recently represented a physician group in Tennessee. A payer had decided to stop paying for an expensive test, indicating the test was investigational and experimental. In addition to ceasing future reimbursements, the payer decided to recoup everything it had paid the physician group for the test in the past, which was a significant dollar amount. In addition, the announcement came with no warning to the healthcare provider. This was particularly troubling because the payer had regularly paid for the test in the past, but suddenly reversed its decision without giving detailed information about how the decision came about. Since most health insurance is an employer-sponsored benefit, most commercial payers are governed by the federal employee benefits law called ERISA. ERISA’s regulations require that any recoupment decision be clearly justified and explained. Payers must share with the provider all the documentation supporting the decision and give the provider an opportunity to appeal. The physician group began a lawsuit in federal court and the matter was settled, with the insurer waiving all of its claims against the group for recoupment. Access related sidebar: When and How ERISA Can Protect a Medical Provider in an Audit SituationAre you seeing any trends in commercial payer audits? Quadrino: Similar to CMS, commercial payers are starting to hire private vendors to review and analyze claims data to identify patterns and reveal potential outliers. Commercial payers are then using retrospective audits to dig deeper into perceived payment anomalies and determine whether overpayment has occurred. For example, one of my cases involved a psychiatrist who practiced in an inter-city area and focused on treating troubled youth. Due to the unique patient population, the frequency and intensity of the patient visits were above the norm for a typical psychiatric practice. A commercial payer began investigating why the provider’s claims were higher than average. After looking into the issue, the private insurer determined it had overpaid the provider and sought to recoup money associated with treatment. Although the psychiatrist’s claims were appropriate for the patient population, the payer disagreed, again not adequately justifying why it sought recoupment. As of today, this issue is still pending and not resolved.Can healthcare organizations avoid this type of commercial payer audit? Quadrino: Detailed documentation is probably the best way to avoid any audit, whether it be from a commercial payer or the federal government. When documentation clearly reflects the care an organization provides and describes the reasons behind that care, it leaves less chance for misunderstanding. Taking time to review your documentation and ensure it accurately and comprehensively indicates the who, what, where, when, and why of patient care is key. You don’t want to leave any room for suspicion or cause the payer to jump to conclusions or make false assumptions.As part of this review, providers should also make sure that the services they provide are necessary and non-duplicative. If a payer believes that services are excessive, it may open the provider up to greater scrutiny. Taking time to bolster medical necessity justification can foster prompt and appropriate payment, and prevent both federal and commercial audits at the same time. While providers can engage in preventive efforts, payers must also take some of the responsibility and reduce their reliance on retrospective audits. Right now, commercial payers often process large volumes of claims without thoroughly reviewing and analyzing them to ensure they are compliant with health plan benefit coverages and provider contractual agreements. This increases the payer’s reliance on using retrospective reviews—often years after payments have been made—as the primary means of verifying compliance. If payers can proactively identify discrepancies between claims and benefit coverage/contracts, and provide more detail about their concerns to providers, then the interaction between payers and providers can be more positive, resulting in more consistent payment and less reliance on audits. Not only is this the right thing to do, but it is what the ERISA legislation and regulations require—a clear and honest exchange of information that leads to prompt and fair processes for payment.
Kathleen B. Vega is a freelance healthcare writer and editor who contributes regularly to HFMA Forums.Interviewed for this article: Richard Quadrino, founding partner of Quadrino Schwartz, New York City. Access related sidebar: When and How ERISA Can Protect a Medical Provider in an Audit Situation
Forum members: Please share your insights, questions, and comments about this article. You can use the "inshare" button at the top of this web page or visit the Payment and Reimbursement Forum LinkedIn discussion board.
Publication Date: Monday, August 05, 2013
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
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