The GAO or the Government Accountability Office has been at the throat of Medicare for some time now. That is because around 2010, nearly $35 billion dollars had been let down the chute by the federal insurance due to improper payments. Now, that is a huge sum of money by any standards. So it is perfectly reasonable to ask, why then have we allowed it to become thus, a White Elephant? And why anything can’t be done about it besides of course torturing the poor souls called physicians in order to satisfy its gargantuan appetite?
Well, one reason could be that any developed nation worth its salt needs a health network to take care of its teeming disease-stricken masses, and for this country it happens to be Medicare. The second could be that, it would be considered almost heresy if one was to point his/her finger at something as huge and archaic as Medicare. So, whether physicians like it or not, Medicare is going to be the hand that feeds them (at least a majority of the time i.e.), and it does make sense then to get to the belly of the beast, so as to better understand its internal machinations.
WHAT THE GAO FOUND :
The CMS, along with its contractors process more than 5 million claims per day. So, unless they have something akin to quantum computers with artificial intelligence as portrayed in sci-fi films, it is a no-brainer that only a few of the claims will be medically reviewed before being paid. Now, how few might elicit a gasp from any healthcare stakeholder. Only around 1% percent of the claims are actually checked thoroughly for medical necessity and other such basic criteria. But when one considers that Medicare is required to pay its electronic claims in between 14 to 30 days, and it receives more than 5 million of them in a workday the math seems to add up. The GAO also found the following:
a. If not a manual review, even automated prepayment checking mechanisms did not ensure that the payments made were accurate.
b. Home Health Services was a particularly sore point, with many Home Health Agencies billing for unauthorized care, in one case close to $10 million. Also many physicians claimed their signatures had been forged on the authorization letters.
c. Medicare’s IPPS or inpatient prospective payment system has been altered continuously for close to three decades to avoid enhanced payments to hospitals; but it is still found that enhanced payments are being offered to 90% of the hospitals.
d. RACs, a new concept in post-payment audits since its inception in 2009 focuses primarily on high dollar discrepancies. Since the regional RAC contractors are paid a fee in proportion to the value of the dollars overpaid, they tend to focus on such accounts.
SQUEEZE THE LITTLE MAN :
So the independent practices and single physicians might feel that with so much amiss within its own house why CMS is squeezing the little man, by both reducing the amounts paid for each of the services, and then having the RACs squeeze them, when in the first place they should have properly analyzed the claims submitted. But, as mentioned at the very top, the above point is not open for discussion (at least for the near future). Also, as additionally mentioned one should increase one’s knowledge of the institution in order to stay clear of denial pitfalls. This may be done alone, but as they say “it takes 2 hands to really clap”, and a partnership with a medical billing vendor or a revenue cycle specialist may just be what the doctor ordered.
BILLING PARADISE :
With a decade of hands-on experience in servicing over 500 clients when it comes to the RCM Cycle, BillingParadise could be that ideal comrade. And our workforce is particularly attuned to the vagaries of Medicare Payment Methodologies. Call BillingParadise at 888-571-9069 or visit our website at www.billingparadise.com.
