According to the Department of Health and Human Services Office of the Inspector General, the projected recoveries to the federal government from fraud-related audits and investigations are expected to rise 33% -- or by $1.7 billion -- in fiscal 2012.
OIG expects recoveries of $6.9 billion this past year, according to the agency's Semiannual Report to Congress. Some of that recuperation came from the Medicare Fraud Strike Force, which filed criminal charges against more than 300 people or entities and got 181 convictions. It found $1.2 billion from training contractors to identify claims where Medicare is not the primary payer, and $900 million by reducing Medicare payments for durable medical equipment.
The OIG also counted a $3 billion settlement reached with GlaxoSmithKline, a $628 million settlement with Merck over alleged marketing efforts and a $187 million settlement with McKesson of alleged inflation of prescription drug pricing.
Recovery Audit Contractors, while under scrutiny, nonetheless, will still be looking at care providers as the government continues to push to lower costs and eliminate waste.
Steps You Can Take
- Perform a self-audit targeting known vulnerabilities targeted by RAC auditors. Stay abreast of RAC information by subscribing to CMS updates.
- Put in place key processes that can help address and avoid audits. These could include admissions screening criteria; coding reviews and training; and comprehensive case management.
- Likewise put in place the technology to aid these processes.
- Develop a denials management process to monitor and track denials.
- Form a taskforce that meets regularly and can be mobilized upon a RAC request. You don't have much time to respond to a medical records request. So you must organize yourself to respond when the time comes, making sure you have the resources available to make the RAC response a top priority.
- Develop an Appeals Process. Put in a process for mobilizing your taskforce upon notice. Create standardized appeal letters with standard rationale for justifying various claims. Involve your compliance and legal team or your appropriate outside counsel.
- Educate and Simulate. Conduct coding reviews yourself or through a third party. Share the findings with your taskforce. Develop a corrective action plan. Develop ongoing staff training, particularly around coding issues.
Don't expect the scrutiny to go away. Prepare yourself and save yourself headaches down the road.
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