WellPoint Inc. Chief Executive Angela Braly, facing criticism for the insurer's plans to raise rates as much as 39% in California, has chosen to fight back. Instead of issuing an apology, she is turning her critics' argument around, citing rising healthcare costs driven by doctors and hospitals, which she says aren't addressed by current health-overhaul bills, the Wall Street Journal reports. Today, Braly and other top health-insurance executives are expected to appear before the Obama administration's top health official to discuss healthcare premiums.
While RACs are not responsible for reviewing claims for potential fraud, they are responsible for referring to CMS any potentially fraudulent instances found during those reviews.
Another demonstration project RAC notified CMS of multiple claims from Florida providers "involving millions of dollars in improper payments to physician practices for Intravenous Immune Globulin treatments," though it did not formally refer the potential fraud to CMS. In addition, the OIG report stated that CMS directed the RACs to cease reviewing the claims and that it did not track the outcomes of the referrals it received from RACs.
At the time of the demonstration project, CMS provided RACs with a number of conferences and meetings in which fraud issues were discussed, but no formal training was ever provided, the report said. In response to an OIG information request regarding the training, CMS stated, "In order to determine if recovery auditors could work in Medicare, CMS purposely did not provide formal training to the RACs. The RACs needed to prove to Medicare and the provider community that they could work in the Medicare environment. Significant CMS intervention would have clouded the result."
The OIG made three recommendations to CMS based on their findings:
Conduct a follow up to determine the outcomes of the two referrals made during the demonstration project
Implement a database system to track fraud referrals
Require RACs to receive mandatory training on the identification and referral of fraud
CMS agreed with all three recommendations.
Follow up
CMS stated that it researched the cases and determined that they should be referred to the OIG for further development. Up until now, providers have not seen any issues referred to the OIG by the RACs, so this should get everyone's attention, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.
"Providers shouldn't discount this news just because it is coming from the demonstration project. It would be a good idea for providers to review the demonstration project issues, since we do not know what cases CMS recommended for referral to the OIG," says Mackaman.
"The bottom line is that that RACs are out there to make money based on their findings and contingency fees," says Mackaman. "And since they are obligated to report any suspected fraud to CMS, they are, in a sense, doing a pre-cursory review for the OIG."
CMS stated that it's in the process of developing a tracking system for RAC claims review. In the meantime, however, providers should not only review their own RAC's issues, but also be aware of the issues listed by the other three RACs.
"This is a way to organize your internal audits, make corrections where appropriate, and stay one step ahead of what might be coming," says Mackaman. Overall, it would be labor-intensive and costly to monitor all RAC issues lists; however, in the long run, it could pay for itself.
CMS has already provided two training sessions to RACs, and is in discussion with the OIG and the Department of Justice for additional training.
Anticipation of potential problem areas is essential for providers. After that, maintaining awareness of ongoing RAC activity should help a facility avoid any RAC-related fraud possibilities, according to Mackaman.
Massachusetts has appealed to the federal government to help hospitals that care for disproportionately high numbers of lower-income patients who receive state-sponsored health insurance. Governor Deval Patrick is asking the Obama administration for $216 million for Cambridge Health Alliance, the state's only public acute-care hospital, and another $115 million for six private hospitals with high Medicaid patient populations, including Boston Medical Center and Caritas Carney in Boston.
If Jackson Health System runs out of cash, Miami-Dade County would be responsible for paying Jackson's 10,500 union workers, but not necessarily the other 1,500 employees, according to a legal analysis by County Attorney R.A. Cuevas, Jr. It's unclear exactly how big a tab that might be, but it would be a huge chunk of the $86 million of salaries and benefits that the public hospital system spends each month, the Miami Herald reports. At present, Jackson is expected to run out of cash in May or June unless drastic cuts are made.
Despite lobbying from religious leaders and community activists, the Minnesota House failed to override a veto of legislation that would have restored a healthcare program for some of the state's poorest and sickest residents. The House moved toward the vote even after Republicans vowed to uphold Gov. Tim Pawlenty's veto of a plan that would have resurrected General Assistance Medical Care before it expires April 1, the Minneapolis Star Tribune reports. The state now will forge ahead with plans to transfer 32,000 people from the program to MinnesotaCare, a subsidized insurance program.
A consumer group sued Anthem Blue Cross, accusing the health insurer of violating California law by closing certain policies to new members while illegally offering remaining customers alternative plans with fewer benefits at higher rates. Santa Monica-based Consumer Watchdog says in its lawsuit, which seeks class-action status, that Anthem closes "blocks of health insurance business" without offering comparable options, the Los Angeles Times reports.