Medicare Recovery and Claim Review Programs

Overview: The Centers for Medicare & Medicaid Services (CMS) implemented several initiatives to prevent improper payments before CMS processes a claim, and to identify and recover improper payments after processing a claim. The overall goal is to reduce improper payments by identifying and addressing coverage and coding billing errors. The Government estimates that about 8.5 percent of all Medicare Fee-For-Service (FFS) claim payments are improper.

It is difficult to prevent all improper payments considering that the Medicare FFS program processes more than 1 billion claims each year. The CMS uses the Recovery Audit program to detect and correct improper payments in the Medicare Fee for Service (FFS) program and provide information to CMS and review contractors that could help protect the Medicare Trust Funds by preventing future improper payments.

Under the authority of the Social Security Act, CMS employs a variety of contractors to process and review claims in accordance with Medicare rules and regulations. The contractors include Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing (CERT) Contractors - CERT Documentation Contractor (CERT DC), CERT Review Contractor (CERT RC), and CERT Statistical Contractor (CERT SC) and Recovery Auditors.

MACs process claims submitted by physicians, hospitals, and other health care professionals, and submit payment to those providers in accordance with Medicare rules and regulations. This includes identifying and correcting underpayments and overpayments.

ZPICs identify cases of suspected fraud and take appropriate corrective actions. Whereas SMRCs conduct nationwide medical review as directed by CMS. This includes identifying Underpayments and overpayments. CERT Contractors collect documentation and perform reviews on a statistically-valid random sample of Medicare FFS claims to produce an annual improper payment rate. Finally, Recovery Auditors, which are currently on hold, identify underpayments and overpayments, as part of the Recovery Audit Program.

Why should you attend: HHS and Department of Justice (DOJ) announced record-breaking anti-fraud recoveries in $4.2 billion for 2012, and $14.9 billion over past four years. Additionally, CMS recovered $3.16 billion in separate non-fraud overpayment over past three years.

Under the Affordable Care Act, if a provider fails to repay an overpayment, it could be treated as a false claim under the False Claims Act. Among other things, the provider would therefore be at risk for:
treble damages liability for the amount of the overpayment
an $11,000 penalty per individual claim
exclusion from the Medicare program
Don't miss this opportunity to learn what the government is doing to prevent improper Medicare payments. It could help you avoid costly claim denials and recoupments.

Areas Covered in the Session:
What are the types of government claims audits?
Who performs the audits?
What Are The Providers' Options?
What can providers do to get ready?

Who Will Benefit:
Skilled Nursing Facilities
Hospitals
Rehabs
Home Health Agencies
Physicians

Dr. Freville is an independent consultant who advises healthcare clients regarding many regulatory issues including but not limited to compliance and HIPAA/HITECH program effectiveness.

MentorHealth
Roger Steven
Phone No: 800-385-1607
FaX: 302-288-6884
[email protected]
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http://www.mentorhealth.com/