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But today, only days before an expected vote on healthcare reform, we’re working on some fascinating articles here at RACMonitorEnews that all seem to tie together nicely. Not so much articulating doom and gloom, these stories are more along the lines of insight and solutions.


Tomorrow, you’ll read about the OIG report suggesting that the RACs may have a disincentive to refer potential fraud to CMS because they do not receive their contingency fees on cases determined to involve fraud. The report also suggests that CMS did not provide the RACs with any formal training during the demonstration project to identify and refer potential fraud cases. CMS accepted and agreed to the recommendations; in fact, it has incorporated fraud detection training to the permanent Medicare RAC program.


In light of the OIG’s stance on this issue, it is likely that CMS and the OIG will continue to address this shortcoming and refine operational processes to make them more efficient through training and additional monitoring, reports Carla Engle, MBA, and product manager for MediRegs, in her article “Fraud Referrals from RACs Likely.” According to Engle, it is a slippery slope for a RAC auditor not to interrupt fraud investigation activity while also supporting the discovery of possible fraudulent activity.


Medicaid Integrity Program Under Review


The Medicaid Integrity Program has been a concern to most providers who already are under siege with RAC audits and other Medicare audit programs, reports Linda Fotheringill, Esq. in her article this Thursday. Fotheringill thought it would be a good idea to look at what has happened so far with the MIP program to get some sense of what providers can expect going forward.


So how is the MIP doing, Fotheringill asks rhetorically. You’ll be taken aback by what she’s found and her expectations for the future described in her article “The Medicaid Integrity Program: The Difference $180 Million in Appropriations Makes.”


Natural Match Ups


Real matchups can be found just about anywhere – take David Letterman and Paul Shaffer, or the NBA’S Kobe Bryant and Paul Gasol of the Lakers. Even in healthcare, no less – specifically the RACs – there’s a near-perfect matchup with MS-DRG validation and data analytics.


Writes MedLearn’s Carol Spencer in Thursday’s E-news, “with data analytics, you can perform a sweep of your MS-DRG and claims data to discover patterns and potential outliers representative of erroneous claims that may result in improper payments (overpayments or underpayments).” Enough said. In her two-part story, Spencer goes on to explain the need for data analytics, offers good examples and says that there are both internal and external triggers to determine or identify high-risk MS-DRGs, coding and medical necessity. Of the external triggers, she mentions, among others, the “Program for Evaluating Payment Patterns Electronic Report Reports,” or PEPPER.


All of which brings us to an article from Bret Bissey, MBA, FACHE, CHC and the director of regulatory consulting for IMA Consulting. Writes Bissey in his cogent article, “CMS recently announced that it would be continuing its Program for Evaluating Payment Patterns Electronic Report (PEPPER) initiative.”


You may recall that these very informative reports were produced quarterly by CMS until 2008, reminds Bissey in his article “PEPPER Reports to Continue.” One of the stated goals of the PEPPER reports is to help guide hospitals’ auditing and monitoring activities. All of the information released via PEPPER is intended to assist hospitals in identifying overpayments and underpayments.


The report, writes Bissey, analyzes your hospital’s billing and claims data in comparison to other providers for Medicare Severity Diagnosis Related Groups (MS-DRGs) and discharges that are determined to be at high risk for payment errors due to billing, coding and/or admission necessity issues. Sound familiar? It’s all about the RACs.


So, all in all, it appears that the week of the Ides of March is less foreboding that some might think.


See for yourself this Thursday. To receive RACMonitorEnews on a regular basis, simply register on the Home Page at http://www.racmonitor.com/


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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