Medical Review:
Critics- Recovery Contractors Glorified Bounty Hunters
Published on Mon Jan 03, 2005
Home care could be hit especially hard by the pilot program that rewards contractors for identifying overpayments. Paying new Recovery Audit Contractors on a contingency basis is a recipe for disaster for home care providers, warn numerous home care experts.
"Compensation for RACs will be provided through retention of a percentage of the overpayment recoveries," the Centers for Medicare & Medicaid Services explains in a Jan. 10 Medlearn Matters article.
This payment structure "gives them an incentive to recoup money," criticizes Gloria Peterson of the California Association of Medical Product Suppliers. "The incentive is there to collect more." The RAC program will pilot in New York, Florida and California starting in May (see story, this page), and may expand nationwide if the feds like what they see.
With a financial reward "to find something wrong ... we wonder about conflict of interest." says Patrick Conole with the Home Care Association of New York State.
"It's scary," insists consultant John Gaynor with Frost, Ruttenberg & Rothblatt in Chicago, IL. "They have the motivation to come back with sizeable adjustments." Gray Areas Especially Risky Rewarding recovery contractors for making recoupments in home care is especially risky, maintains Bob Wardwell with the Visiting Nurse Associations of America. "The Medicare home health benefit allows for a great deal of flexibility and interpretation in determining coverage," notes Wardwell, a former CMS official.
Contingency payments "are just not appropriate" in home care, which is rife with gray areas, agrees Gene Tischer with state trade association Associated Home Health Industries of Florida. "There are honest differences of opinions" where clinicians are obligated to make judgment calls, Tischer says.
"It's just wrong" to have contractors get paid for coming down on the other side of such a decision, Tischer insists.
Having it be in contractors' best interest to find a recoupment "whether it's right or not" makes them into "bounty hunters," criticizes Joan Cross, past president of the Florida Association of Medical Equipment Services. "They'll come in here looking for blood," worries Cross, with C&C Homecare Inc. in Bradenton, FL. Gear Up For More Review Requests Even if the RACs don't find anything wrong with your claims, responding to additional medical review requests will mean more work for you, points out Conole. The workload impact could be significant depending on how a provider is staffed, he tells Eli.
If an RAC does deny or downcode a claim and you have to appeal it to your usual contractor, that will take even more time and money, Tischer adds. Learn a Lesson from CERT Unless CMS, intermediaries and DME regional carriers start a pretty intensive education campaign before the recovery pilot begins in May, many providers probably won't even reply to medical review requests from a contractor they [...]
