The Comprehensive Error Rate Testing (CERT) Hospital Payment Monitoring Program is one of the ways CMS is trying to improve the quality and accuracy of Medicare claim submission and payment of those claims. Is that so different from what the RAC program is designed to do?
While the end-goal may be the same, the methodology is very different. Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City, outlines some of the important differences between the two types of Medicare audits:
Who is being audited. RACs look for errors made by providers, but the CERT is looking for errors in payments made by carriers. Hospitals and other providers are affected because when the CERT looks into a claim, the provider must submit the medical records, and if the CERT uncovers an error, the CERT will take back money from the hospital. But the CERT is really looking for errors made by fiscal intermediaries, Medicare administrative contractors or other carriers when paying providers' Medicare claims.
Education. "CERTs want to make sure everything is on the up and up for the claims," Levitt explains. When the patterns of incorrectly paid claims appear on its radar, the CERT steps in and educates providers. RACs don't provide such education.
Payment. RACs are paid through contingency fees. The more under- or over-payments they uncover, the more money they receive. The payment for CERTs is different; they receive a set amount outlined in their contract, regardless of the percentage of payment errors they find.
Size of the program. The RAC program has gotten much more attention than the CERT program, but it may be because the RAC program has the potential to be a much bigger headache for providers. The CERTs examine random claim samples—often only looking at a very small percentage of a carrier's claims. So the CERT would likely request only a small number of medical records from providers paid by that carrier. And the potential takeback, if any, would likely be smaller as well.
However, there are some similarities between the two programs. Both auditors report to CMS. And both will recoup money from hospitals and other providers who received overpayments.
Providers can also appeal any claims they believe were wrongly denied by a RAC or CERT. The process for RAC appeals has been widely discussed, but providers can also go through the appeal process for a CERT denial. "It's not just a de facto takeback," Levitt says.
In addition, CERTs will still use OIG statistical methodology. "They're still bound to that just like the RAC is—for example if a RAC wants to extrapolate," she says. "Everybody is held to the same statistical standard such as the OIG statistic program, RATSTATS."
It's hard not to notice the number of products making claims that they can help ward off the flu. A spot for an over-the-counter pain medication, for example, starts with a fraught mother wringing her hands and telling the camera she's so worried about her family catching the flu this year. The voiceover goes on to explain that the product can relive the aches and pains associated with flu symptoms. Fine—but what does that have to do with the woman's fears that her kids will catch the virus in the first place?
There's also been an uptick in the number of ads for anti-bacterial cleaning products that used to make allusions to icky germs (such as one memorable ad that showed a woman blithely cleaning her kitchen with a raw hunk of chicken). Now they're all focused on the H1N1 virus. Clorox, for example, has an admittedly clever spot in heavy rotation that shows friends passing around a bottle of bleach that implores viewers to share with their friends tips on how to avoid the flu. And guess what? This week Clorox announced a 23% rise in first-quarter earnings, according to a New York Times article.
Meanwhile, the claims these household brands are making are nothing compared to the Web sites hawking products that claim to prevent H1N1—from ionic silver to vitamins and other supplements. The FDA is cracking down on the snake-oil supplements that illegally claim to prevent or treat H1N1 without FDA approval—it's identified about 140 sites making such claims. Further, it's warning consumers about fake Tamiflu that's hit the market.
OK, already, you get it. So what should you do about it?
Education is the obvious answer, but healthcare organizations are already overwhelmed with calls and visits from worried consumers. So look to online to help spread the message.
Some suggestions:
Link to FDA warnings about bogus products on your home page—in a prominent location. The agency has even created a neat little widget you can place on your site to help your staff and consumers identify fraudulent H1N1 products. Other widgets, including an H1N1 news feed and a map of the U.S. that shows state-specific flu information, can be found on the HHS flu widget page.
Consider setting up a Twitter feed (branded to your healthcare organization, of course) or a Facebook group that not only pushes out articles and information about H1N1, but also answers consumers' questions. For the latter, you'd need to monitor the site in order to respond promptly. And make it easy for searchers to find you on Twitter by adding the hashtag #H1N1 or #swineflu to each of your posts.
Alternately, if you already have a Twitter feed (and one is quite enough, thank you), follow and re-tweet accounts set up to share H1N1 news. (Find them by searching for the hashtags above.
Don't forget to position your physicians as experts on the topic. Consider adding video or other content on your Web site, blogs, and social networking sites of one of your physicians helping consumers to sort out the facts versus the fiction of the H1N1 virus.
In a letter to healthcare professionals yesterday, FDA Commissioner Margaret Hamburg, MD, acknowledged "delays in vaccine delivery and the persistence of myths about vaccination" and offered talking points for explaining to patients that H1N1 vaccines are "the best tools we have to prevent severe illness and death caused by the virus."
I'd argue accurate, easy-to-understand, and easy-to-access information is an important tool, too.
Note: You can sign up to receive HealthLeaders Media Marketing, a free weekly e-newsletter that will guide you through the complex and constantly-changing field of healthcare marketing.
With the House of Representatives' narrow approval of its health reform bill Saturday, the next stop for the health reform train is the Senate, which will soon begin debating its own plan that was approved by the Senate Finance Committee.
The House passage was praised by many as a landmark achievement, but we're still a long way off. During the next few weeks (or months), legislators will battle for pet reforms while stripping away others.
Here is my prediction for three health reform ideas that will stay and three that will go:
Three that will stay
Medicaid expansion.
The final health reform plan will make it easier for poor and lower middle-class Americans to get insurance through Medicaid.
The House bill would allow individuals and families with incomes at or below 150% of the federal poverty level to be eligible for Medicaid. The Senate will probably come up with a not-as-generous level, but the two sides will develop a plan that will allow thousands of new Medicaid beneficiaries.
This will somewhat satisfy those who decry healthcare system access, but won't please doctors, hospitals, or states.
The feds will provide funding in the transition, which may increase Medicaid reimbursement in the near term, but doctors and hospitals will not like having more of its patients covered under state Medicaid programs.
More insurance regulations coupled with a watered down individual mandate.
President Barack Obama has made it clear health reform will target health insurance. Obama and the Democrats want more health insurance regulation, including not allowing rejections because of pre-existing conditions or charging higher rates to women (who insurers say cost more to insure than men), or those who are in worse health.
Insurers are OK with those added regulations as long as health reform requires all or most Americans to buy health insurance. The insurance industry wants the mandate because they know it will flood the market with young adults who are historically not interested in health insurance. These new, low-cost members will help pay for the new, sicker members.
Insurance exchanges that will allow consumers to compare health plans online.
An insurance exchange will be seen as a compromise to a public plan. The federal government will likely seed billions to states to help them create Web sites, public outreach, and staffing so residents will have an easy one-stop shopping experience for health insurance.
These Web sites will give states control while satisfying Republicans and conservative Democrats, who will see the exchanges as a way to help consumers buy insurance rather than expanding government-run healthcare.
Three that will go
A public plan.
For the past few months, I have predicted that a public plan will not be part of the final health reform package and I have not been convinced otherwise.
In the final analysis, I don't think the federal government wants to create another program that could cost more than expected. The Senate will likely discuss a compromise public option, such as Sen. Olympia Snowe's trigger plan, but I think the feds will pass the issue onto the states through expanding Medicaid eligibility.
A powerful individual mandate.
The good news for insurers is that health reform will likely include an individual mandate. The bad news is that I don't think it will have much teeth.
Many members of Congress are against an individual mandate with a heavy fine for those who don't buy insurance. Opponents of the idea don't want the government telling Americans what to do and/or don't want to place financial burdens on individuals who choose to not buy health insurance, particularly those who can't afford it.
This opposition is coming from both sides of the political spectrum, so I think ultimately Congress will pass a wishy-washy individual mandate that will sway many, but not all, of the 47 uninsured Americans to acquire health insurance.
Taking away health insurers anti-trust exemption.
Democrats added this idea to the health reform debate shortly after America's Health Insurance Plans released a study that charged current reform proposals would cost Americans more money.
From the start, taking away the exemption has been used as a weapon and bargaining tool against the health insurance industry.
It's not going to be part of the final health reform bill.
If my predictions come true, you can see that health insurers will dodge a bullet with health reform. Yes, there will be more regulations, which aren't ideal for insurers, but there will be avenues to bring in new, younger, and healthier members, such as insurance exchanges, a limited individual mandate, and Medicaid expansion.
President Obama has said he wants a healthcare reform bill on his desk by the end of the year. The Senate Democratic leadership is going to try to meet that goal, but it likely will face some major obstacles along the way.
Senate Majority Leader Harry Reid (D NV) on Tuesday night moved the Democrats out of the gate by starting the process to place the newly approved House reform bill (HR 3962) on the official Senate calendar. When placed on the calendar, a motion to proceed to start debate can be called the next legislative day.
However, since the Senate is off for the Veterans Day recess, Reid could file a motion to proceed as soon as Nov. 17 when the Senate returns. But Reid most likely will need an actual Senate healthcare reform bill that has been scored by the Congressional Budget Office (CBO) to move forward.
The Democrats are awaiting CBO action. Some have suggested that a CBO score could be available as early as Thursday or Friday. But even with the score, that does not mean that Democrats are out of the woods yet: They are likely to encounter a Republican filibuster on whether the Senate should even take up the bill in the first place.
Sixty votes are needed by Democrats to stop a filibuster in order to do what is known as invoking cloture—or putting the legislation in motion. Getting the 60 votes could be tricky: For instance, Sen. Joe Lieberman (I-CT), who has traditionally voted with the Democrats, has said he would support a filibuster with a bill that contains a public insurance option.
But even if they overcome the filibuster, the Democrats likely could encounter another Republican maneuver: Requirements that the text of the full bill be read on the Senate floor. Traditionally, members of the opposite party waive that formality because having a Senate clerk read the bill aloud could take many days.
Since Reid has promised senators that they will have a Thanksgiving recess, action would resume after Nov. 30. Unlike the House, which took one day to pass its bill, the Senate is expected to spend days—and most likely weeks—debating amendments. They likely would meet Monday through Friday during the first three weeks of December.
When asked about the timeframe yesterday, Senate Minority Leader Mitch McConnell said, "The Senate is the place where the American people get to weigh in . . . where there are amendments on a whole broad array of issues."
He added that in years past, large chunks of time had been devoted to debate—such as four weeks last year for a farm bill or eight weeks several years ago for homeland security measures. Therefore, drawing out several weeks for healthcare reform might not be that unusual.
Even if a Senate bill is approved, addressing such major issues as a public option and taxes on benefits could take time. And even with bills approved, both chambers still have to reconcile their versions and vote on the completed bill.
So will the Senate be able to "take the baton and bring this effort to the finish line on behalf of the American people," as Obama asked on Sunday? Time will tell.
The Senate majority leader, Harry Reid of Nevada, said that he expected to bring major healthcare legislation to the floor next week and to complete work on the bill before Christmas. But other Democratic leaders said it was unlikely that a bill could reach President Obama's desk by year’s end, the New York Times reports. Reid still has not finalized the Senate version of the legislation. He is waiting for additional analysis by the Congressional Budget Office, with a goal of keeping the 10-year cost of the bill at the roughly $900 billion suggested by President Obama.
In the two weeks since the Senate majority leader, Harry Reid, embraced a proposal that would allow states to opt out of a new government health insurance plan, state leaders have begun debating whether to take part. The proposal, which is being woven into the Senate healthcare bill, would give states the right to opt out of only the public plan, not from the tax increases needed to subsidize coverage for the uninsured. Several state officials said that if Reid's proposal carries, many governors are likely to accept the new plan rather than incite an ideological battle mirroring the fight in Congress, the New York Times reports.
Former president Bill Clinton urged Senate Democrats to resolve their differences with a healthcare bill and pass an overhaul as soon as possible. Using the lessons of his own history with healthcare reform, Clinton noted the grim consequences of the failed reform effort 15 years ago, when he was in office: Democrats lost control of Congress in that year's midterm elections, healthcare costs skyrocketed, and the rate of Americans without insurance continued to rise.
Federal officials have indicted an Atlanta radiologist on charges he never reviewed thousands of X-rays and other imaging tests for patients in the Southeast, but had his non-physicians review them instead.
Rajashakher P. Reddy, 39, president of Reddy Solutions, Inc. (RSI), allegedly "provided radiologist coverage—interpreting x-rays and other films—to various hospitals in the Southeast that otherwise typically lacked full-time radiology coverage," according to a statement from acting U.S. Attorney Sally Quillian Yates.
Reddy faces up to 20 years in prison and a fine of up to $250,000 for each count of wire fraud, mail fraud, healthcare fraud, and obstruction of justice, according to the statement.
"This case shows a clear violation of the public trust," said Office of Inspector General Acting Special Agent in Charge Carl D. Bocchicchio. "Ensuring the integrity of healthcare programs remains a top priority."
From May of 2007 to January 2008, "Reddy signed and submitted thousands of reports in his name without even reviewing the films that were the subjects of the reports. Rather, he had non-physician technicians, known as Radiology Practice Assistants, review the film and prepare the reports," the statement said.
According to the statement, "In some cases, Reddy directed the RSI staff to simply sign for him, and transmit the report" as if he had prepared it. "The indictment alleges that the majority of the time he never looked at and analyzed the underlying films, and the reports signed by him therefore did not bear his medical conclusions or those of any other doctor."
The statement did not indicate whether any patients were harmed, went undiagnosed or misdiagnosed because their tests did not receive a radiologist's review. The U.S. Attorney's Office statement does not include any allegations that Reddy fraudulently billed insurance plans or government payers.
The case is also under investigation by the Federal Bureau of Investigation and the Office of Inspector General of the U.S. Department of Health and Human Services.
Maine's legislators have tried for decades to fix its healthcare system, but their efforts have always fallen short: health insurance premiums are still among the least affordable in the nation, healthcare spending per person is among the highest, and hospital emergency rooms are among the most crowded. Many overhauls to the system have done little more than solve one problem while worsening another, reports the New York Times, and the state's history is a cautionary tale for national health reform.
