Part B Insider (Multispecialty) Coding Alert

Published on Mon Sep 11, 2006 PDF

P4P train 'has left the station,' CMS says

If you thought you were safe from the Recovery Audit Contractors (RACs)--it's time to start worrying again.

Congress appointed the RACs to investigate claims in Florida, California and New York, and they get paid based on how many overpayments they find. The RACs had been focusing on hospital claims, but now they're turning their attention toward physician claims.

Good news: The Centers for Medicare & Medicaid Services changed the rules for the RACs, CMS officials reassured the Practicing Physicians Advisory Council at its March 6 meeting. Now instead of just receiving a percentage of the overpayments they find, they'll also receive a percentage of the underpayments they find. That means they have an incentive to find money that Medicare owes you.

"We have no problems with them doing what they do," says Ronald Castellanos, a Cape Coral, FL urologist who chairs the PPAC. "We just wanted to make sure they were incentivized to look for underpayments as well," says Castellanos. 

Target: The RACs will mostly be looking at outpatient and surgical procedures, including radiology, pathology and general surgery, Castellanos explains. But they'll be able to look at E/M claims if they see excessive overbilling.

P4P Could Cost You Thousands

One CMS official told the PPAC meeting that "the train had done left the station" for pay-for-performance (P4P), according to Joe Johnson, a Paxton, FL chiropractor and PPAC member.

Some PPAC members were concerned that P4P plans could provide small rewards in exchange for buying technology that could cost $42,000 to install and $16,000 per year to maintain. Others raised questions about what measures would be applied and how Medicare would collect information on them.

At least at first, you'd receive more money for meeting P4P guidelines. But Johnson worries that a few years down the line, doctors could actually be punished with reduced reimbursement if they fail to follow quality guidelines.