Code Correctly to Avoid RAC Audits at Your Practice
Code Correctly to Avoid RAC Audits at Your Practice
On December 17, 2012 CMS published “Medicare Fee-For-Service Recovery Audit Myths.” Try as I might, more eloquent words cannot better describe my thoughts, than the two-word colloquium preferred by my 13-year-old: “Defensive much?”
The “myths” sought to be debunked are (in no particular order):
1. RACs deny every claim that they review.
2. Every RAC denial is overturned on appeal
3. RACs have non-clinicians conduct review of medical records
4. RACs create their own policies and are not bound by CMS regulations
5. RACs can review as many claims as they want from a provider
6. RACs don’t have physicians on staff
7. RACs do not tell anyone what they are reviewing
8. RACs outsource all the medical review to staff in India and the Philippines.
Twenty-five years of trial experience have taught me many lessons about the art of persuasion. Chief among these is a simple rule: “Hostile” audiences will usually disregard the “negation” of any declarative statement. (“We are [not] out to get you,” will generally only serve to validate an unreceptive audience’s suspicion.) I could only ponder what might motivate CMS to produce this “RAC Apologist’s Manifesto.” Unlike John Adams’ explanation for his defense of the British soldiers accused of the Boston Massacre (“somebody had to do it,”) I can’t begin to imagine what CMS hoped to accomplish.
CMS’ argument, (RAC auditors aren’t incompetent buffoons,) not only begs to mind the obverse inference, acceptance of the premise ignores Office of the Inspector General's (OIG's) Regional Inspector General Ann Maxwell’s congressional testimony six months prior which directly criticized Medicaid Auditors misidentification in all but 25 of 113,378 files reviewed (auditors were wrong in 113,353 out of 113,378 cases)—because the auditors don’t know what they are doing.
The years have also taught me an additional lesson: It is a good idea to spend less time marveling how clumsily an overwhelming enemy wields its sword, when time could be better spent “getting out of the way of the strike’s thrust.”
So I called my friend, Mary Pat Whaley, a coding expert with Manage My Practice, LLC, based in Durham, N.C., who agreed to share some of her insights.
MM: What can physicians do to minimize the chances of an unfavorable audit?
MW: There are a number of things physicians can do immediately to reduce risk of adverse audits:
Mary Pat Whaley
First: Clear up the confusion over midlevel providers (MLPs)
Most practices use nurse practitioners or physician assistants to provide care to patients.
Few are sure, however, of the rules surrounding billing for MLPs. There’s a good reason for this; most payers, including Medicare, have individual guidelines for reimbursing MLPs.
Second: At least annually, internally audit your coding/billing department,
your billing service or third-party vendor.
Maybe you’ve had turnover in your coding or billing department, or maybe you wonder if your billing service is doing everything exactly right. If you have coders (in-house or third-party) assigning/abstracting codes from your medical records, they should be audited annually to make sure you are protected. Top-notch coders and billers will welcome an opportunity to have their work audited, and if your coders, billers, billing service, or third-party vendors are defensive about an audit, it should make you wonder why. The good news is that one of the best risk management strategies you can have is a solid coding and billing compliance plan, and an important part of the plan is the annual audit. You will find it difficult to protect yourself against compliance issues if you do not perform annual monitoring and auditing as required by the OIG.
Third: Do not assume either newly hired physicians, or seasoned veterans understand and are properly trained as to CMS’ current expectations.
Many physicians come out of residency with little or no coding or documentation experience. Often, veteran physicians with a great deal of practical experience are not current on CMS’ ever-expanding expectations. New physicians and all new hires, regardless of practical experience, should have initial education on coding and documentation and should be audited when they have been seeing patients for four to six weeks.
Fourth: Proper training and regular outside auditing is an excellent defense against the dual hazards of over- and undercoding.
I find that many of my clients are so fearful of the consequences of “overcoding,” they needlessly sell themselves short. The truth is, “overcoding” and “undercoding” are like navigating between “Scylla and Charybdis.” Overcoding certainly carries the danger of a devastating audit, but conversely, your practice cannot survive if you are not charging appropriately for what you do. This is where an outside coding consultant can help.
…While no amount of diligence or experience can guarantee a clean bill of health, it is important to realize the RAC audit program is so new, many RAC auditors are learning as they go. An experienced independent coding consultant with years of experience may be able to explain with greater certainty and conviction exactly what CMS manuals require.
Physicians and the Health care industry are so highly over-regulated that any "logical" solution will land the Medical Doctor with Civil Monetary Damages and a multi-year jail sentence. The best suggestion is for a physician to become good friends with a health care lawyer.
Richard Willner
The Center for Peer Review Justice
That is my view too. who created these codes? I don't go to college to learn these codes. Why spend my time leaning this and worrying about being audited/
Just pay by the time.My plumber charged me $75 to just to turn on a switch! I did not know that was what was needed. I had to pay
Hilarious comment. The AMA created these CPT codes to accurately describe what services were to be billed. You went to college and medical school to have a physician business, which most physicians are not taught in medical schools. Complain to the medical schools for not teaching you , your medical practice business. Yeah, most physicians want hourly pay, but not really practiced or supported. Maybe you should have learned more about that, before graduating.
Patrick
RAC is a very important tools to keep honest physicians in Business. they should Audit every clinic with out notice at least twice per year.
If we move to the model of" Physicians on Salary" and no incentive for over volume.
and practice Medicine as a "Public Service" not a way for high income and easy life style,
The country Healthcare cost will bed down by 20%-50%.
But paying for # of people we see and for the coding we use,, make the human greedy.
Physicians should start on a Salary of $75K on low cost areas and $100K in New York, Miami.
The "AMA" closed many medical schools around 1909. It is time to open more affordable Medical schools and use the Salary model with limit on hospital CEO income.
Time Article by Mr. Berreall is goo to read.
If the medical education 7-11 years (sometimes more) post college were provided without cost to the individual. If the process of torts for medical malpractice were change to a commission-granted award for injury, paid by premiums from patients and insurers. If the innovation of medical treatments were fostered by awards, this low-ball scenario salary might make some sense. As it is, we reward the wrong people in society for entertainment. It is nauseating.
RAC gets a cut on the recovery. It's easy for an angry employee to retaliate against an honest physician and practice. There is no easy and inexpensive for the physician to fight that audit. Fraud is fraud and should have equal punishment. However fraud by a physician had ten times the monetary fines then the same amount if fraud committed by business or law industry. There is value to a physician or surgeon, and I hope you value that heart or brain surgeon more than attorney that earns well over $300/hr or expect to pay him more than the plumber that jacked up your toilet. You get what you pay for, just look at any socialized medicine country and try getting a joint replacement, heart surgery, or any modern and timely medical treatment. Paying your brain surgeon $25/hr and your landscape guy $30/hr makes perfect sense M. Good luck getting your knee replacement done by the lowest paid and lowest caliber surgeon.
Given the expense and time put in to become a physician in this country, this is an ignorant statement. Additionally, to state that physician salaries are a significant contribution to the inflated cost of healthcare adds another layer of ignorance to this statement. Not even sure why I've bothered to acknowledge the comment with this reply. The fact that you've described what we do as an "easy lifestyle" indicates you are not a physician, but an armchair critic.
Please tell me "Which job is an easy job & which job is an overpaid job"?
MD is the only job in this country immune from the ups and downs in the economic cycle.
The AMA is the strongest labour union in this country which give Physicians and secure jobs and secured high income compared to the Median house hold income in USA=$47K.
in 1995 Physicians expense was 12% of health care cost, now (2010) it is about 24%.
Average Salary was $200K on 1996, Now (2010) it is about $400K.
Same for hospitals CEO's health insurance CEO..etc.
MD are the 1% an a class by themselves and Patients are the 98%.
The current system is transfer income from the middle class to the 1%
Where Are You Getting These Numbers From? They Are Completely Inaccurate. Also, OUr Salaries Have Not Gone Up In Fifteen Years...So No, We Are Not Immune To Economic Hardship. And How Far Does A Primary Care Salary Of 100K A Year Go (With No Healthcare, Retirement Or Other Benefits) When You Graduate With 300K In Debt? Teachers Make More Than That, And Have Far Better Lifestyles
here is the problem , MDs' are not the only group have $300k student loans. If we support Higher Education and get college education with $zero debt. $100K with +27% benefits and 3-4 weeks vacation
is a goo start, however still we need to look at DDS, RN, PhmD, CEOs'''etc.
Getting to double the # of MDs' then the hours would be 40-50 hours per week.
However, many PhD in history, Anthropology from Ivy League have $200K+ student loans and a job for $50K.
Graduates MD from Africa, India, Pakistan,, are her with %zero debts. It is normal they come to USA to make money,, if they pay is $75K-$100K many will stay home helping their poor countries.
That said, Many MDs' work 50 hours per week, which is what most people do these days, but for $30K per year.
Yeah...I DonT Think' I Had Eight Years Of Higher EdUCation, Seven Years Of Residency And Work Eighty Hours Or More A Week IncluDing Nights, Holidays, And WEekends, So ThaT I Could Work "Public Service." I Don't Think Reasonable Compensation IS Much To Ask For. Where Did That High Income And Easy Lifestyle Comment Come From? I Have Neither
Patrick, are you an M.D.?
RAC is a very important tools to keep honest physicians in Business. they should Audit every clinic with out notice at least twice per year.
If we move to the model of" Physicians on Salary" and no incentive for over volume.
and practice Medicine as a "Public Service" not a way for high income and easy life style,
The country Healthcare cost will bed down by 20%-50%.
But paying for # of people we see and for the coding we use,, make the human greedy.
Physicians should start on a Salary of $75K on low cost areas and $100K in New York, Miami.
The "AMA" closed many medical schools around 1909. It is time to open more affordable Medical schools and use the Salary model with limit on hospital CEO income.
Time Article by Mr. Berreall is goo to read.
You are so uninformed. First, in order to decrease the Healthcare expenditure, you would need to place limits on technology and end of life care. No one wants to address that issue. 2.
RAC should be more often and private insurance should reject un-needed surgeries.
My surgeon asked me to do 3 surgeries,, I got a 2nd opinion,,I needed ZERO surgeries.
There are many variables to reduce healthcare cost. Administrative cost, Physicians induced demand,
audit hospitals and physicians for ordering un-needed surgeries,,,Hospitals CEO's and Physicians high income. Tech. Insurance overpay..
there is "NO" single college degree guarantee you will be in top 25 or 0.05 % of the earners in the country
except the MD degree.
It's absurd being in top 1% from the pain of other fellow citizens.
Physicians should be on Salary (net Gross income after covering the pay for staff, nurses,, and malpractice insurance)
for $75k for PCP up to $150K for orthopedics surgeon,, etc.
then adjust this income to the cost of living "ACOLA"
Once Medicine become a public service such as teaching,,etc. We can look at the rest of healthcare cost.
Michael,
Obviously you're either not an MD or someone who went to medical school without having to pay for the tuition. How in the world can any doctor pay off a $300K loan with a $75,000 annual salary? How can you encourage any intelligent young person to go into an occupation with high tuition and low income, not counting having to spend a great deal of time in their prime in schools and hospitals, just like boot camps? I used to want my kids to be MD's, but not anymore. I don't want them to work every other weekend like I do. I don't want them to work half of the holidays in a year either. All of my non-medical friends have their weekends and holidays off.
The RAC audit is just a another scam just like the HCAPS. It is just a way not to pay the physicians for the work that they did. Wait until you yourself get audited and having to hire a lawyer to defend yourself, then you'd fully understand what I am talking about.
No one is asking to under pay anyone. The problem here is the culture of practicing medicine and the reason to go to Medical School. the problem will be here even if the Med school are free.
once we educate the society and start from pre-K educating people that Medicine and healthcare is a from of "Public Service" such as Police Man/women and Fireman/women. once we change such expectations and culture- healthcare cost will be down and affordable.
For example a Ph.D in Anthropology takes 8-10 years p-plus the undergrad, and master degree=12-15 years. Such PhD's are happy to make $50k per year. Why? they like what they do, and ther got the expectation to make a little above the median of the household in USA=$48K .
Hotel manger get in call and stand up on their feet for 16 hours per day.
Once we change the culture that the MD degree is not the way for a top of the line Lexus and $1million+ house. And to get any woman or man to marry , healthcare cost will go down and PCP will be happy making $75K= 50% above the Medcian household.
Medicine is NOT the onlt hard work. however Physicians are the only Labour who never get unemployed during any economic cycle.
that's why RAC is very important. Should do more Audit and penalize surgeon who ask clients to do unneeded surgery.
I had my family member in the hospital recently. I am gracious to have such intelligent, well educated and well trained United States educated physicians caring for myself and my family. I have traveled extensively and have seen first hand multiple socialized healthcare plans. We are fortunate to be here in the United States. Our current medical system requires very intelligent and diligent students to progress and actually succeed. My/our physicians sacrificed most of their young lives training so as to help all of us with technology most people have never even heard of. I have never encountered a profession where someone stays awake for days on end, works unbelievable hours and still get criticized for not doing enough.
I would prefer to not comment on this disjointed from reality armchair critic, my time is better spent micturating amongst other things.
One might even consider the forementioned laborious luke warm air to be an April fool's joke but I am afraid the individual actually believes what they have written. This person likely uses tobacco product as well.
There is a reason nonmedical doctorates desire tenure. thay also don't have such lifesaving skills or responsibilities either. Socialized medicine is just that, good luck. There are many reasons non-Americans come here when they can and need to.
If someone is unhappy with physicians, then don't use them. Apply to medical school. hopefully these individuals have the ability to focus more than 5 minutes at a time, compete with classmates to obtain high class rank and high GPA, then good luck getting into medical school. Then spend more than a decade training while pilling up huge debt. wouldn't be a bad idea to consider alternative living arrangements if you are not already institutionalized.
need we say any more? It is extremely difficult to have intellignet discussions when across the table struggles with type II personality disorder, difficulties at home and church, hates their grade school school teachers and probably was bullied growing up by only God knows from whom. this individual probably has a huge stockpiles of discarded remnants obscuring their hallways and floors at home.
be nice to your physicians. You will probably need their help soon for multiple reasons.
It is quite inappropriate for the writer to characterize honest differences in interpretation as “misleading” and “dishonest.” To paraphrase the Bard, “methinks the writer protests too loudly.”
M-you are a total idiot and obviously have an issue with physicians who have given up their 20's to hold someone's hand, learn how to draw blood, start IV's , do surgery , deliver babies and oh yeahmaybe save someone's life. Somehow I think that deserves more money than a PHD in anthropology or whatever. Most hardworking physicians work an average of 60- 80 hours per week - so take the amounts they make and divide it by that and you might see that we are lucky to make decent living by the hour. If you pay me $75,000 year you had better not expect me to be there at 2 am to catch your baby and then do a whole clinic the next day, or stay up all night with a sick patient. Or hold your hand- you are right- I won't see more patients- I will see less and have alife again- maybe you are right! You might just have to wait 2 hours instead of one to see me- what is my motivation to see more? . I hope you know how to take care of yourself- I sure as hell wouldn't want you for my patient. Your attitude is exactly why we are in the situation we are in- uninformed and unappreciative about what it really takes to be a doctor- Good luck!! Fini.
So it is all about money, about making what is the top 1% or 0.5% are making over $400K-$700K, not the love to serve and help. Why MD charge uninsured people 50%-100% more than insured people.
What about setting a (net) salary after all cost of rent, insurance, staff of $50 per hour?
is fair? what about $100 per hour. Why you do not want to do your job and HELP as many sick people regardless of pay.
What about the firman says I am not going to help in more than 2 houses in fire per day because the pay is not good.
Why Only MD, NP, RN can say they will not see more sick people if they do not afford Mercedes S 550 Lexus 460 and $1.5 million $ house??
Every year they (AMA) threat not to help the old on Medicare and the poor on Medicaid unless the congress pay them more.
Fireman risk their life,,, and they are on fixed income.
This prove the point, the culture of practicing medicine is money not public service.
Who can afford $100 -$150 for 5-10 minutes visit for a clinic. And induced demand
France, Germany, UK are doing very well..why? because they learn from Pre-K that being in health care is a public service.
Does the government regulate pay in CEOs, lawyers, stockbrokers, hedge fund managers, entertainers, athletes, politicians, lobbyists, etc. How many of them make millions a year? What service do they do humanity? Who sues them for not performing to perfection? How many of these individuals would you trust with you or your family members life?
Physicians and Surgeons are worth something more than the hourly pay M and others such as him/her are arguing for. What if Derek Jeter or Buffet was paid hourly the day they started their profession? I think most physicians do innately love the art of healing and the service to humanity. They do appreciate the respect and love from their patients and community. That however doesn't mean they don't deserve to be compensated. I agree that for some compensation is the only goal, but RAC does nothing to prevent unnecessary surgeries.
Do you have any idea what socialized medicine is like, go live in Canada or UK, etc. I have relatives that tell me horror stories about the rationing and lack of care. And believe me the compensation for physicians in those countries us well above the 75-150K range that M proposes.
Get real. The true cost of physicians and their services is around 8% of healthcare expenditure. Address the other 92% of the cost first rather than the most important part (the MD with the knife to your brain or the trauma surgeon seeing you in the ED). Nobody would want the lowest paid professional in that OR holding the knife, or the one who gets paid hourly to run the trauma.
Most physicians give a significant amount of charity care, and always discount cash paying patients, or forgive bills (despite Medicare considering it fraud to no bill any patient). Who runs the free clinics (not the anthropologists), how many lawyers will answer your call on weekends, late nights, or take care of your needs on holidays?
Medical care is expensive, but the physicians reimbursement is the only thing that's decreased over the past 30 yrs. Medicare paid close to $2,000 for a joint replacement in the late 80s, it currently pays $1200. Additionally, the surgeons fees are 5-7% of the total cost of a joint replacement today.
Let's decrease the payments to Big Pharma, Hospitals, Insurance Companies, the Government and see what happens.
Glad the debate is on. And you have time to get engaged. The $100K is not a proposal..It is just a figure to discus given the Median household income (family of four) in USA is about $47K.
As for # of hours, you got police man who works 15 + hours per day for $60k per year, and answer as many call at midnight (with risking their life, to save lives). Soldiers in Iraq risk their lives for much less money and more hazardous work environment. Therefore the # of hours and worked by physicians
and treating people etc.. is not a valid excuse to make $400K -$800k per year.
However , the broken system of healthcare in USA is NOT salaries only. it is induced demand, hospitals billings,, administrative cost,, overpriced drugs,, and so on.
I hope we can blog to debate one issue at a time.
* The culture of practicing medicine and the culture of going to medical school need to be changed.
Physicians in USA are the highest paid in the world.The research shows, many physicians induce demand and do many surgeries as DDS try to do many crowns and other treatment,, just to maintain their revenue and net income to be $400K+. Since 1% of the populations are making $360K plus,,
The issues of compensation of health care labour need to be examined in addition to all other variables that making health care so expensive and increase 2-3 times higher than inflation rate.
** Let us worry first about Obama's "Chained CPI first for the poor who depends on their Social Security income for living.
It is quite inappropriate for the writer to characterize honest differences in interpretation as “misleading” and “dishonest.” To paraphrase the Bard, “methinks the writer protests too loudly.”
In response to M's comment, payments to Physician's account for only 11% of all healthcare spending.
Do you have a "reference"?
other sources shows 22%-25% for Physicians Payments & services".
do you have a survey for MD and students at Med Schools why they choose to go to the schools of MED??
I guess at least -over 51% said Money and high income,, and afford XYZ.
very few sais to help their sick Americans or sick human.
Correction. I should have said physician income. The numbers are compatible: with 50% average overhead income would be 11-12.5%.
Leonard Davis Institute
http://ldihealtheconomist.com/he000024.shtml
ONE point, USA has about over 20% of it's skilled healthcare workforce (MD, RN, DDS,,) either born outside USA or got their MD/ MBBS degree from outside USA. 100% of them are in it for the money, not for the mission to treat sick people. Then the other 80% ,, If we survey them,, at least 60$-90%
they went going to and/or to Medical school for the $$ money, and Prestige,.. NOT for the mission of healing and treatment.
This prove my point. Once we start a public campaign and education that "healthcare (including parm.D, hospitals, health insurance,, is a public service" as it is for police, fireman, military,,, .
healthcare cost will never be under control.
As we will not accept the police decline to attend for calls for help, MDs. RN,, etc. should attend for any call for help on a Fixed income. and some overtime.
Michael,
Does it matter? Does this discussion require only MDS?
Physicians have allowed themselves to be duped into accepting the coding process. Stop the insanity. Do what the attorneys, electricians, and plumbers do - charge by the hour. Forget the codes, forget the audits, put a diagnosis on the receipt and present the patient with a receipt for services rendered with a diagnosis.