I. INTRODUCTION

/ strong> prepare p the audit work of health insurance has increased! The Centers for Medicare and Medicaid Services (CMS) Recovery Audit Contractor (RAC) program is permanent, is expanding nationally, starting this year. Radiology providers must act now to ensure they have adopted and implemented appropriate compliance programs. Radiology providers must make efforts to understand the appeal process and health insurance should know that are many strategies that are used successfully in the appeal process controls, to defend Medicare.

II Recovery Audit CONTRACTORS

Section of the 306 Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) directed the Department of Health and Human Services (HHS) to a demonstration for three years with behaviors JRC. The event began in 2005 in the three states with the highest spending in Medicare: California, Florida and New York. Councils were responsible for the identification and correction of overpayments of insurance or are inadequate, and were compensated on a contingency fee basis. The goal of the demonstration program was to determine whether the use of RAC to identify a cost effective manner and to correct improper Medicare payments.

The RAC demonstration program is very “profitable” from the perspective of the CMS. During the three-year demonstration, the RACs identified and collected 2.7 million refund overpayments and underpayments to 0.8 million U.S. dollars in Medicare and suppliers. created based on information from CMS, the RAC demonstration program costs only 20 cents for every dollar back to the Trust Fund for health insurance.

Section 302 of the tax relief and Health Care Act of 2006 made the RAC program permanent and requires the expansion of the RAC program nationally later in 2010. CMS now actively progressing with this expansion. In the last months of the demonstration program, advisory boards in South Carolina, Massachusetts, Arizona and broadened. CMS plans to expand to 19 states in the summer of 2008, four states, most in the fall of 2008, and other states in January 2009 or later. CMS plans to announce the name of the RAC “permanent” provider shortly after 31 July 2008. Provider of radiology in the first 19 countries expected the entry into force of the RAC audit work shortly after the announcement of the RAC “permanent” provider.

Although the regional councils are responsible for correcting inadequate, and that the overpayment is the process of recovery of alleged overpayments, which is especially important for Medicare providers. demonstrated in the last three years, identifies the JRC and collected 2.7 million of overpayments and recovered only 0.8 million U.S. dollars in underpayments to Medicare and suppliers. For example, 96 percent of the payments would have erroneously been overpayments, underpayments opposed to. Councils are allowed to try to improper payments made from the following:

identify? improper payments;
? non-covered services (including services not reasonable and necessary);
? incorrectly coded services (including DRG coding errors), and
? duplicate services.

During the demonstration project, raised concerns about Medicare and suppliers, some aspects of the RAC. CMS has made efforts to address these concerns, and has adopted many changes to the current program to implement. Some of these changes are as follows:

? As part of the RAC demonstration program, the RACs have been allowed to open claims of up to four years after the original due date. Amid arguments that returns the period of four years provider “no fault” provisions of the Social Security Act, under the permanent RAC RAC program reviews a maximum term of three years back hurt again. In all countries (regardless of the date of the extension), the current program with a review of compensation under the first Begin in October paid 2007th However, as time passes, the CCR from the review of claims by more than three years after the date of payment will be banned.

? Under the RAC demonstration program, the cars are not required to undergo a medical director or medical coding employ experts. However, under the permanent program if the coverage of the scene or coding review of medical records a provider of health insurance or providers have been required, nurses (RN) or therapists required to make decisions on medical necessity and certified coders are required to coding decisions . take Councils are not obliged to include doctors in the review of medical records, but the regional councils are required to at least one full-time equivalent contractor medical director (CMD), a doctor or organize employ a doctor of osteopathy and an alternative, if CMD CMD for a longer period is not available. CMD will provide services such as advising staff of the RAC regarding the interpretation of the policy.

? As mentioned above, CMS GFS is like on a contingency basis, reimbursed based on the principal amount of the collection (or amount), a supplier. As part of the demo program, the regional councils have the right to keep their fees, if a rejection was confirmed in the first phase of the appeal, regardless of whether the supplier has prevailed in a later stage of the complaint. Check the arrangement fee provided incentives to proactively CCR and denies the claims, including claims may not be invoked “medically necessary” is an area with a lot of subjectivity, and called for a class of denial often from the suppliers. In fact, 40 percent of the alleged overpayments identified during the demonstration program for reasons of medical necessity was rejected. For their efforts, the Centre received 7.2 million in emergency payments in the event (or approximately 14.4 percent of all allegations of improper payments) were identified. In a significant change in the demonstration program, under the RAC program permanent, if an applicant files an appeal challenging a decision overpayment and win this appeal to all levels, the RAC has no right to keep his fees must be conditional and CMS reimburse the amount received for the recovery. are

health insurance companies nationwide do well to prepare for the increased activity of RAC and Medicare audits now. Although providers can not stop RAC audits occur, they can make this implementation of appropriate compliance programs and efforts to understand the defenses available verification.

III. COMPLIANCE
nationwide Medicare providers would be wise to prepare for the RAC audit activity and increased Medicare now. Radiology providers can devote to the preparations of resources:

? Internal monitoring protocols to better identify and monitor areas that can be controlled;

? Reply to record in a timely manner;

? Compliance efforts of execution, including but not limited to documentation and coding education. Remarkably, in addition to claim denial of medical necessity and due to insufficient documentation and coding, it is also possible to obtain denials asked if services are not provided in accordance with Medicare regulations. Therefore, the provider of services Radiology ensure that well-documented and coded, and also ensure that the supplier have been met with Stark, the general anti-branding, the rules of the practice of teleradiology moral teaching of medicine and Standards IDTF (if any) among other rules, and

? function properly until the opposition proceedings in the appeals process challenging. In terms of medical necessity and similar denials to bring the obvious to find with the participation of doctors, many non-physician suppliers and hard to get.

IV TESTS Medicare – The Medicare appeal process

As stated above, if a Medicare provider or supplier receives a denial request, or the determination of overpayment is the result of RAC review, the refusal to be subject to the Single Medicare Part A and Part B appeals process. The rules of this process is contained in 42 CFR § 405.900 et seq

Step 1: redefinition
The first level in the appeals process, a new decision. The wholesale requests decision in writing within 120 calendar days after receiving notification to submit the original provision. There is no controversy in height requirement.

Step 2: Review
provider disagrees with the decision makers for a review may file an application for review must be performed by a qualified independent contractor (QIC). This second level of appeal must be made within 180 days after receipt of notification of the new decision may be filed. There is no obligation in dispute is at this stage of the appeal.> The provider must have a complete and timely submission of evidence in the review stage. provide for the submission of an application for review must be a provider, evidence and allegations concerning the case and explain the reasons for the disagreement with the original decision and a review. Absent good cause, failure of a supplier to a hearing before issuing the notice to deliver on the assessment includes further analysis of the evidence. Consequently, suppliers can not be allowed to prove, in the later stages of the appeal process be introduced if the evidence presented at the review stage.

Step 3: Administrative Law Judge

The third level of appeal is the Administrative Law Judge (ALJ hearing). A supplier with a new decision may request a hearing ALJ dissatisfied. The request must be made within 60 days of receipt of the QIC decision to re-submitted, and must complete a required amount in controversy. ALJ hearings ) can be conducted in person or by telephone. Regulation by video-teleconference (VTC writes the hearing by VTC shall be implemented when the technology is available, but if VTC is not available, or in other exceptional circumstances, the administrative body may judge a hearing in person can. In addition, the administrative judge to offer a telephone consultation.

Step 4:> Medicare Appeals Council Review

at the request of the parties a reasonable MAC opportunity briefs file or written statements may be. In addition, a party an opportunity for hearing apply there. The MAC will apply for this grant if the case raises an important question of law, politics, or indeed not decided easily on the basis of the written comments be.

Step 5: Federal District Court

The final step in the appeal for judicial review before the Federal District Court an application for revision before a district court must be submitted within 60 days of receipt of the MAC decision are. In an action in Federal District Court, the factual findings of the Secretary of HHS to be conclusive if supported by substantial evidence.

V. STRATEGIES FOR THE DEFENSE of Medicare TESTS

health insurance companies are subject to testing or RAC insurance should understand that are many policies that lead can be used successfully on appeal effect to significant results. These strategies are effective advocate the merits of the underlying services and the use of legal defense.

Defending When praised the merits of a claim, the lawyer for the moral health of radiology help suppliers often find it useful to create a document alignment to support in the factual and legal arguments, the payment of a disputed claim. In addition, in most cases it is advantageous to engage the services of a qualified expert. The appropriate use of an expert can be very useful, especially if the examination is the denial of medical necessity. In arguing the merits of other strategies that may prove fruitful is the use of medical abstracts , illustrations and colored charts or graphs showing the claims in question, which are friendly to the decision makers.

Defenses test A doctor treating the rule B. Disclaimer

After the liberation of Medicare

defense responsibility, doctors may be entitled to payment of claims as not reasonable and necessary by the carrier during an audit. The statutory power of waiver of liability is defined in § 1879 (a) of the Social Security Act. will have to pay under the waiver of liability, even if a service does not determine reasonable and necessary, but made the payment if the provider does not know and could not reasonably expect would. The crucial question is whether the provider “knew or ought reasonably to find,” have the payment is not made. Therefore, in the defense of an examination, a doctor must have access to all relevant communications carrier with the suppliers of the community and the communication with the respective suppliers. The repeal of the liability rules in the rule apply only to decisions that the service was medically necessary. If a radiological department is deemed not appropriate and necessary to an argument about a potential supplier of radiology could make in the context of the theory dismissed the wavier of liability is that he did not and could not reasonably expect that the payment would have to inquiry be carried out because the doctor had specifically provides that the services provide reasonable and necessary for patient care.

C. Vendor without fault> It is generally considered to be a provider through no fault into account when they accept reasonable care in billing and payment, namely has exercised the provider with all relevant requirements; disclosure Fill in all the essential facts and on the basis of available information, had reason to believe that the payment was correct.

“failure” for the purpose of providing no-fault provider is defined as follows:
(a) a misrepresentation by the person he knew or should have known were inaccurate,

(b) withholding of information he knew or should have known, material or

(c) With respect to the individual on the acceptance for payment, which he knew or should have known to be expected, was wrong.

As with waiver of liability if a radiology department will not be denied reasonable and necessary, is an argument that could make a provider of radiology in the framework of the standard provider, is no doctrine, did not know and had reasonable not made be expected that the payment does not know about the request, because the doctor had explicitly determined that the services provide reasonable and necessary for patient care.
will also be regarded providers without fault in the absence of contrary evidence, if the overpayment was after the third calendar year following discovery of the payment.

D. recognize reopening regulations

health insurance regulations, leave that in the interest of fairness,
Medicare provider ust on the determination of m range. Accordingly, allows restrictions on Medicare legislation of the period for the reopening of judgments. According to federal regulations governing the appeal process for Medicare after a first decision, a claim has been filed, the application for the examination in a given period will be open again.

b After 42 CFR § 405 980 (), the reopening of a contractor and may reconsider its original decision: 3 At any time if there reliable evidence as defined in Section. 405.902, that the original decision was due to fraud or other misconduct within the meaning given in sec. 405.902.

4 At any time if the initial decision is adverse, in whole or in parts to the party, but only for purposes of correcting a clerical error on the basis of those facts.

After 42 CFR § 405 986, “good cause” is presumed if:

1. There is new evidence and documents

i was not available or known at the time of the finding or decision, and

II Can a different conclusion, or> E. Challenges statistics In the tests after the payment of many CMS audit of a small sample of records from a provider and, if an overpayment, the CMS overpayment will extrapolate to the entire patient population of the supplier. The MMA establishes limits when the statistical extrapolation can be used, and the Medicare manuals to follow guidelines for the CMS, where the implementation of an audit based on statistical sampling. If an extrapolation is not correct, it can be successfully challenged, bringing the total dollar amount for the “real” the alleged overpayment, in extrapolating the alleged overpayment. By example, in one recent case contested by the law firm that allegedly CMS an “actual” overpayment of about 000, which was then extrapolated, a decision that the seller was too much make up to 0,5 million €. The company has successfully challenged the methodology of statistical extrapolation and extrapolation was canceled.

According to Article 935 of the MMA:

(1) limiting the use of extrapolation. A contractor can not be with sick extrapolate the amount of the overpayment by means of recovery, offset, or otherwise determine if the Secretary-General notes that –

(A) there is a sustainable level or high payment error or

(B) is documented educational intervention against the billing error corrected.

CMS has also established guidelines Guidelines for statistical projections, the manual for the integrity of the Medicare program (CMS Pub outlined. 100-08, Chapter 3, § § 3.10.1 of 3.10.11.2). Specifically, the RACs are permitted to use extrapolation unless they mention with the law and the provisions of the manual. CMS and its suppliers must meet these guidelines in the implementation of follow statistical extrapolation. If he should do this, not a provider of “insurance can succeed in challenging the validity of the extrapolation.

VI. Radiology providers to be prepared for the audit work, the Medicare program increased RAC cover nationwide. Radiology providers must now make efforts to assess their compliance with the policies of insurance. If a provider or supplier is subject to a test or other Medicare RAC, effective strategies are available that are used successfully in the appeal process controls, defend Medicare .

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