Payment Matters

December 20, 2011

Prepayment Review: CMS Signals Changes that May Be in Store for the Recovery Audit Contractor (RAC) Program

By: Mark A. Stanley

CMS has announced a demonstration project that will allow RACs to conduct prepayment review of claims in 11 states. Aside from the fact that RACs will review claims prior to payment, the review process will be identical to the post-payment process currently employed by RACs. The affected states include seven states, Florida, California, Michigan, Texas, New York, Louisiana, and Illinois, which were selected on the basis of population and error rates for claims. The four remaining states, Pennsylvania, Ohio, North Carolina, and Missouri were selected based on the states’ high claims volume for short inpatient stays.

Welcome Clarification for Home Health Face-to-Face Documentation Requirements

By: Carel T. Hedlund

Home health agencies (HHAs) experiencing payment denials for inadequate documentation of the face-to-face encounter have gained a measure of relief from CMS’s recent clarification of these requirements [PDF]. Some Medicare contractors have been using a hypertechnical reading of the documentation and signature requirements to deny payments in situations where the home health episode follows an acute or post-acute stay. In these instances, the community physician who assumes care of the patient after discharge and who is responsible for overseeing and updating the plan of care often signs a single form (the CMS-485 form) that contains both the plan of care and the certification of the need for home health services. The acute or post-acute physician certifies eligibility and the need for home health services and is signing an addendum containing the documentation of the face-to-face encounter. The problem has been that the acute/post-acute physician is the one doing the certification of need, but the 485 has only one signature line so it appears that the community physician is signing the certification.

Quality Measures Under Consideration for Agency Programs

By: Kristin Cilento Carter

CMS published a list of 366 unique quality measures that are currently under consideration across 23 of its programs (List of Measures Under Consideration). These include quality measures being considered for inclusion in, among other programs, the e-Rx Incentive program, Ambulatory Surgical Center Quality Reporting program, the Hospital Inpatient and Outpatient Quality Reporting programs, and the Value-Based Purchasing Program.

The List of Measures Under Consideration was published in accordance with a statutory mandate set forth in Section 3014 of the Affordable Care Act, requiring CMS to establish a “pre-rulemaking process” for the selection of quality and efficiency measures. This process includes the following:

Final Rule on ESRD PPS and Quality Incentive Program Issued

By: Susan A. Turner

On November 10, 2011, CMS published a final rule that updated and made certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012 [PDF]. In the same rule, CMS also finalized the final rule with comment period originally published on April 6, 2011, regarding the transition budget-neutrality adjustment under the ESRD PPS, and set out requirements for the ESRD quality incentive program (QIP) for payment years (PYs) 2013 and 2014.