Home Health & Hospice Week
Contractors To Scrutinize Your Claims More Closely
Medicare payment error rate increases. The Centers for Medicare & Medicaid Services Dec. 13 unveiled the Medicare error rate - alongside a promise to breathe down your contractor's neck until the rate improves.
In fiscal year 2004, the error rate for fee-for-service claims was 9.3 percent, compared to last year's adjusted rate of 5.8 percent. FY 2003's unadjusted error rate, which includes non-responses, was 9.8 percent.
The majority of this year's errors were due to insufficient documentation. Other problems included non-responses to requests for medical records, medically unnecessary services and incorrect coding.
But CMS says new "detailed performance monitoring" of individual Medicare contractors will more accurately measure error rates in Medicare payments - and slash that rate down to 4 percent in four years. Durable medical equipment regional carriers had an error rate of 11.1 percent while fiscal intermediaries' rate was 15.8 percent.
Among DMERCs, Palmetto GBA (Region C) had the worst error rate at 14 percent while Adminastar Federal (Region B) fared the best with 6.6 percent. CMS did not separate out error rates for regional home health intermediaries.
Redoubled compliance efforts will likely mean more attention to your claims this fiscal year.
To improve error rate medical review responses, CMS notes it has extended the timeframe from 55 to 90 days (see Eli's HCW, Vol. XIII, No. 39, p. 309). In 2005, it will try other solutions like accepting electronic records in small tests and more education.
The 2004 error rate short report is at www.cms.hhs.gov/CERT.
Jacqueline O. Richardson was sentenced last year for illegally receiving $385,000 from Medicaid for nonexistent business transactions. In a recent appeal, Richardson argued that the sentencing did not apply because the offense involved a large number of victims - and she did not know they were "vulnerable." Under sentencing rules, jail time can increase by two levels for offenses against "vulnerable victims."
The U.S. Fifth Circuit Court of Appeals affirmed the 10-year sentence, and reminded that sentencing guidelines provide a four-level increase for offenses involving 50 or more victims, according to its Dec. 6 decision (No. 03-51000). "Richardson knew that the victims, most of whom were over the age of 65 and physically disabled, were vulnerable," the decision reads.
Prosecutors charged Richardson's original scheme was promising patients supplies that were never delivered, not appropriate or were substandard, according to Texas Attorney General Greg Abbott.
The GAO asked six questions 70 times each, and checked the call center reps' answers against the model answers provided by CMS. The topics of the questions included power wheelchairs, drug cards, Medigap, Medicare Part B enrollment and eye exams.
Providers aren't faring much better: An August GAO study warned providers that their Medicare carrier's call centers are only giving them correct answers to policy-oriented questions about 4 percent of the time.
The new 1-800-MEDICARE report is at www.gao.gov/new.items/d05129.pdf.
CMS has established 26 regions in the nation for Medicare Advantage Preferred Provider Organiza-tion health plans in 2006, HHS Secretary Tommy Thompson has announced. "Medicare beneficiaries will be able to save on their health care and prescription drug costs by joining a Medicare health plan," Thompson urges in a release.
"We particularly wanted to make sure that there will be plenty of opportunities for beneficiaries who live in rural communities to have access to lower-cost health plans, something that didn't happen with the Medicare+Choice program," CMS Administrator Mark McClellan says in the release.
Home health agencies have had a notoriously difficult time getting managed care plans to approve home care services approaching anywhere near Medicare service levels, they say.
For five years the supplier allegedly paid physician Delia Garcia Romeu more than $30,000 for signing off on fraudulent certificates of medical necessity for DME including oxygen concentrators, ventilators and hospital beds, prosecutors said back in May (see Eli's HCW, Vol. XIII, No. 21, p. 166). The false certifications resulted in 1,600 claims, they charged.
Flores' son, Francisco Giron Flores III, faces 31 charges in the matter and is scheduled for trial in late January, the newspaper notes. Dr. Romeu died in a car accident in July.
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Contractors To Scrutinize Your Claims More Closely
Medicare payment error rate increases. The Centers for Medicare & Medicaid Services Dec. 13 unveiled [...]
