"Can You Hear Me (Us) Now??!"

I wish I had coined that phrase years ago! So many of us responsible for education, training and consulting within the healthcare industry feel that we sometimes speak to deaf ears regarding some basic components related to payment and reimbursement, documentation, medical coding, claim creation, billing and compliance. If you have not really "heard" and taken substantive action to improve in these areas, now is the time.... you need to hear me (us) now!

The Affordable Care Act (ACA)

The new Affordable Care Act (aka Healthcare Reform), signed into law in March 2010, has changed and will continue to change the face of all aspects of healthcare for patients, organizational providers, physicians and payers (lots of ‘p's there).  Some provisions of the act are gaining more notoriety than others, with the total package not yet even fully developed or understood.  Some in our industry are hoping it will "go away" or be revised in the future so we can say now that "we really don't have to DO anything about it, and we have enough to contend with these days anyway!"

Ok, let's be clear..............we all MUST take notice of certain components of this legislation and address our internal issues NOW, because tomorrow truly will be too late; the still-new RAC program is but a portend of things to come!

In a letter dated June 8, 2010 from HHS Secretary Kathleen Sebelius to Attorney General Eric Holder, she underscored certain components of the Affordable Care Act about which we must all sit up and take notice: "the President has directed the Department of Health and Human Services (HHS) to cut the improper payment rate, which tracks fraud, waste and abuse in the Medicare Fee for Service program, in half by 2012." http://www.hhs.gov/news/press/2010pres/06/20100608a.html

What You MUST Hear?!

The Affordable Care Act will improve and expand government-wide healthcare initiatives by identifying and fighting fraud and waste, and it includes new tools to prevent, detect and take action against fraud in Medicare, Medicaid, the Children's Health Insurance Program (CHIP) and also private insurer enterprises. The act also amends the False Claims Act to provide that a violation of the latter's anti-kickback statute constitutes a fraudulent action. The new act defines an "overpayment" as "any funds that a person receives or retains (from a federal payer) to which the person, after applicable reconciliation, is not entitled."

Through "Expanded Overpayment Recovery Efforts - the Secretary (of HHS) (has) provided new authorities to identify and recover overpayments through the expansion of the RACs to Medicaid, Medicare Advantage and Part D (the Medicare drug benefit). Providers, suppliers, Medicare Advantage Plans and Part D Plans must self-report and return Medicare and Medicaid overpayments within 60 days of identification."

(See  http://www.healthreform.gov/affordablecareact_summary.html) for a summary or the key points in the ACA.)

I have bolded that last statement to make the point we must all take note of this. In the past, internal or external compliance reviews perhaps may have identified overpayments and/or errors, and providers may have chosen to hope no one finds out, failing to report the matter or return funds.  Or, in the alternative, providers may have been slow in reaching a decision on how best to manage this over an extended period of time; under the ACA, however, the time frame is 60 days from the point of identification, and overpayments and errors must be self-reported! Frankly, if not reported or returned, these mistakes will come back to haunt providers when they come to light, which they eventually will, and likely sooner than later!

Mandatory Compliance Plans

Compliance plans, formerly voluntary in nature for healthcare providers, now are mandatory..........REALLY!  No formal date has been announced, however in a May 13, 2010 news conference, the OIG through Dan Levinson stated "Prevention efforts such as compliance programs are integral to curbing healthcare fraud, waste and abuse. Under the ACA providers and suppliers will be required to adopt compliance programs that meet a core set of requirements to be developed by the HHS Secretary, in consultation with the OIG."

Did you notice what was said at the end, specifically "to be developed by?" This area has not been developed, and most of us to date have relied upon the OIG 7 elements of a compliance plan, or the "7 Key Elements of Compliance Programs" to construct our plans/programs (these recently were reviewed in a RAC Monitor Webinar on May 20, 2010).

In the future, HHS with assistance from CMS will look at determining the specific requirements for compliance programs/plans and will make them a "condition of enrollment" as a Medicare/Medicaid provider.