CMS is going after Medicare Over payments in a big way. Just like Willy Sutton, they are going to where the money is. Does your CFO know if there are overpayments and how much they are worth? Have you done any focused reviews to unearth this information? The tools for CMS to unlock your vault are very advanced and ready for deployment. After all it is a Mission to “take back the PEOPLES’ MONEY. In this election year this matters. So it must be taken very seriously.

Equally challenging is that CMS and in the OIG Work Plan physician practices are targeted in a new dimension: they will look to obtain evidence that within Medical practices there is an Internal Compliance Plan that identifies Medicare overpayments. In essence, CMS wants to see evidence that such a program of compliance is in effect for every practice small or large.

Perhaps it is the Election year pressure but we at Health Systems Management Network are hearing from our clients that they are seeing audit requests (Not RAC) already for both their Physician practices and Hospital admissions. To further complicate these processes, there have been a few requests by private insurers to look at physician billing and compare it to hospital billing for patients.

For almost thirty years Health Systems Management Network has advised its Physician clients to have such a plan and be ready to show the frequency of audits and the results. Assuming that encounter or procedure has been done there remains the question of whether the level of treatment/procedure have an appropriate diagnosis, is medically necessary all clearly documented and not simply copied from Macros in the Software of the Electronic Medical Record. This is the challenge of our time.

How does an institution (acute care facility) know where to look. Precision is critical in identifying potential areas and being correct in assuring they have found the overpayments. This is not an easy task especially with the ACA. Repaying overpayments for the previous six years isn’t merely a task, it is a program that requires a commitment of staff, appropriate analytics, the ability to compare physicians, procedures, professional billing and the hospital claim to assure accuracy

We have advised our clients, both physician and Hospitals to begin a program starting with accurate analytics to identify and target Claims which need review. Clearly the Revenue Cycle team must be included to confirm claim details and calculate potential over or under payments. This requires reviewing Medical records to assure supportive clinical documentation, precise coding, and making sure that all info on the claim match the service provided.

Health Systems Management Network has never participated in RAC reviews but have provided hospitals, faculty practices and other providers with assistance in doing such reviews. Our team is built around professionals who focus on the Revenue Cycle and the Medical staff. Hospitals and physician practices should develop internal mechanisms. Sometimes help from and experienced and independent source can make this effort move faster and leave lasing results for continuing to stay compliant

There is not time to waste because every hospital and each physician practice with significant Medicare volumes are the targets. After all, Willy Sutton knew which banks had the most money and he told the police after capture, he robbed those banks because “that is where the money is”. Just think of CMS, Medicare, the FBI, and OIG as knowing where the money is and finding it in overpayments. CMS has had success in unearthing intentional fraud in the Medicare program and now they are going after what most of us would label as “Unintentional”.