The Centers for Medicare & Medicaid Services (CMS) is escalating efforts to reduce improper payments through several demonstration projects that will focus on reducing overall payment errors.
CMS has earmarked 11 states for the Recovery Audit Prepayment Review Demonstrations, due to questions about high levels of fraudulent activities and/or high volumes of claims on short inpatient stays. These states include: California, Florida, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas.
In this demonstration project, Recovery Auditors will evaluate claims before they are paid to ensure compliance with all Medicare payment guidelines, initially focusing on inpatient hospital claims for short stays.
Specifically, Florida’s Medicare Administrative Contractors are establishing prepayment reviews for 15 Diagnosis Related Groups (DRGs):
MS-DRG Description
226 Cardiac defibrillator implant w/o cardiac cath w/ MCC
227 Cardiac defibrillator implant w/o cardiac cath w/o MCC
242 Permanent cardiac pacemaker implant w/ MCC
243 Permanent cardiac pacemaker implant w/ CC
244 Permanent cardiac pacemaker implant w/o CC/MCC
245 AICD generator procedures
247 Percutaneous cardiovascular procedure w/ drug-eluting stent w/o MCC
251 Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC
253 Other vascular procedures w/ CC
264 Other circulatory system O.R. procedures
287 Circulatory disorders except AMI, w/ cardiac cath w/o MCC
458 Spinal fusion except cervical w/ spinal curv/malig/infect or 9+ fusion w/o CC/MCC
460 Spinal fusion except cervical w/o MCC
470 Major joint replacement or reattachment of lower extremity w/o MCC
490 Back and neck procedure except spinal fusion w/ CC/MCC or disk device/neurostim
Under the demonstration project, the provider can resubmit the claim to receive 90 percent of the payable Part B claim amount, waive appeal rights, and participate in CMS education related to appropriate patient status assignment. The demonstration will be limited to 380 hospitals and will be accepted on a first come, first serve basis up to a minimum number of small, medium, and large facilities.
The Recovery Audit Prepayment and Part A and Part B Rebilling Demonstration projects will be conducted for three years, from January 1, 2012 through December 31, 2014.
For more information please, contact the experts listed below at PYA, (800) 270-9629.
