Medicare reimbursement | The Health Law Firm Blog

Excess Readmissions Mean Lower Medicare Reimbursement Rates for More than 2,000 Hospitals, Including 131 in Florida

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Lower Medicare reimbursement rates are coming in October of 2012, to 2,211 hospitals around the country, including 131 in Florida. This is allegedly due to excessive readmission rates in these hospitals between July 2008 and June 2011, according to the Centers for Medicare and Medicaid Services (CMS). This story was originally reported by Kaiser Health News on August 13, 2012, and by other sources.

Starting in October 2012, Millions of Dollars in Penalties will be Deducted from Medicare Reimbursements.

Starting October 1, 2012, penalties will be deducted from Medicare reimbursements each time a hospital submits a claim.

All together these hospitals will give up about $280 million in Medicare funds over the next year as the government begins a push to start paying health care providers based on the quality provided, according to the Kaiser Health News article. The government apparently considers readmissions a prime symptom of an overly expensive and uncoordinated health system.

The CMS records show nine hospitals in Florida, including Florida Hospital in Orlando, will deal with a one percent (1%) decrease caused by the penalties.

To see the 2013 Medicare readmissions penalties in Florida, click here.

Medicare Attempting to Lower Readmission Rates.

According to the CMS nearly two million Medicare beneficiaries return to the hospital within a month of being discharged, costing Medicare $17.5 billion in additional hospital bills. CMS states the national average readmission rate is slightly above nineteen percent (19%).

Who Will Lose the Most Medicare Funds?

The penalties will fall heaviest on hospitals in New Jersey, New York, the District of Columbia, Arkansas, Kentucky, Mississippi, Illinois, and Massachusetts. Hospitals that treat mostly low-income patients will be hit particularly hard as well. This is all according to the report by Kaiser Heath News.

The analysis of the penalties shows seventy-six percent (76%) of the hospitals that have a majority of low-income patients will lose Medicare funds.

More Than 1,100 Hospitals Will Not Be Penalized.

The CMS report found 1,156 hospitals with acceptable readmission rates. Those hospitals will not lose any money. The analysis showed, on average, the readmission penalties were lightest on hospitals in Utah, South Dakota, Vermont, Wyoming and New Mexico. Idaho was the only state where no hospital was penalized by Medicare.

The Maximum Penalty to Increase Next Year.

The CMS notes the maximum penalty will increase to two percent (2%) starting in October 2013, and then to three percent (3%) the following year.

These penalties are part of an effort by Medicare to use its financial backbone to force improvements in hospital quality.

On top of the readmission reduction program, on August 27, 2012, the CMS will begin the Recovery Audit Prepayment Review (RAPR), in which Recovery Audit Contractors (RACs) will review a number of hospitals’ Medicare claims.
I previous wrote about the RAPR, click here to read that post.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Rua, Jordan. “Medicare To Penalize 2,211 Hospitals For Excess Readmissions.” Kaiser Health News. (August 13, 2012). From: http://www.kaiserhealthnews.org/stories/2012/august/13/medicare-hospitals-readmissions-penalties.aspx?referrer=search

Kaiser Health News. “First Hospital Penalties for High Readmissions Detailed.” Kaiser Health News. (August 13, 2012). From: http://www.kaiserhealthnews.org/daily-reports/2012/august/13/quality-issues.aspx?referrer=search

Health News Florida. “Readmit Rates Cost FL Hospitals.” Health News Florida. (August 13, 2012). From: http://www.healthnewsflorida.org/hnf_stories/read/readmit_rates_cost_fl_hospitals

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

By The Health Law Firm|2024-03-14T10:00:34-04:00June 1, 2018|Categories: In the Know, Medicare, The Health Law Firm Blog|Tags: audit defense attorney, Centers for Medicare & Medicaid Services (CMS), defense attorney, false billing, health care fraud, legal defense lawyer, medicare, medicare audit, Medicare fraud, Medicare fraud attorney, Medicare investigation, Medicare overpayment, Medicare reimbursement|1 Comment

Revised Readmission Penalties are Coming Due to Calculation Errors

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Back in August of 2012, I wrote that lower Medicare reimbursement rates were coming to more than 2,000 hospitals around the country due to excessive readmission rates. To see that blog, click here.

In October of 2012, the Centers for Medicare and Medicaid Services (CMS) announced it has discovered errors in its initial calculations. This means, 1,422 hospitals with high readmission rates will lose slightly more money than first expected, according to Kaiser Health News.

Click here to read the entire article from Kaiser Health News.

Hiccup in Medicare’s Hospital Readmission Reduction Program.

According to Kaiser Health News, the revisions were relatively small, averaging two-hundredths of a percent of a hospital’s regular Medicare reimbursements. Florala Memorial Hospital in Alabama will see the largest increase in its reimbursements, from 0.62 to 0.73 percent.

Originally, Medicare said it would base the penalties on the readmission rates for patients who were discharged from July 2008 through June 2011. According to a notice the CMS published, the mistake happened because the agency accidentally included claims before July 1, 2008, in its evaluations. Click here to see the notice from the CMS.

Program Initiated to Lower Hospitals’ Readmission Rates.

According to CMS, nearly one out of five Medicare patients will return to the hospital within a month of being discharged, these readmissions cost the government $17.5 billion in 2010. Medicare has estimated, with this program, it will recoup about $280 million from hospitals where too many patients return.

To see an updated list of hospital penalties, click here.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think about this story? Does this error by the CMS leave you jaded about the program? Leave any thoughtful comments below.

Sources:

Rau, Jordan. “Medicare Revises Hospitals’ Readmissions Penalties.” Kaiser Health News. (October 2, 2012). From: http://www.kaiserhealthnews.org/Stories/2012/October/03/medicare-revises-hospitals-readmissions-penalties.aspx

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Cardiologists Face Higher Scrutiny by CMS

By Lance O. Leider, J.D., The Health Law Firm

As the U.S. population ages and heart disease continues to be a leading cause of health issues, cardiologists and cardiology practices are finding themselves billing Medicare for more and more visits and procedures.

Along with that increase in reimbursement from Medicare comes an increase in scrutiny. According to the Centers for Medicare and Medicaid Services (CMS), more than sixteen percent (16%) of total Medicare spending in 2010, was for cardiovascular care.

Some experts predict that this number will increase as cardiologists continue to adopt state-of-the-art technology and procedural techniques when treating their patients.

All of this means that whistleblowers, Recovery Audit Contractor (RAC) auditors, Zone Program Integrity Contractor (ZPIC) auditors, and CMS’s data mining services are going to be more incentivized to come after cardiovascular reimbursements.

To read more on the high scrutiny cardiologists face, click here to read an article on Modern Healthcare.

The Audits Are Coming.

Cardiology physicians and practices need to understand that just because they are doing things the “right way” does not mean that they will not be the subject of an audit. Auditing can be triggered by any number of things ranging from disgruntled employees, competing practices, dissatisfied patients, random audits, above average billing for certain codes, etc. None of these triggers means that a practice is doing anything wrong, but it will have to face an audit nonetheless.

Being prepared before an audit happens can be the most effective defense. Review some of these prior articles and blogs we have written for tips in establishing audit protocols and handling audits in general:

– Self Audit Now to Save Your Practice Later
– Responding to a Medicare Audit – Practice Tips
– Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 1
– Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 2

The Best Defense for an Audit is to be Prepared Before an Audit Happens.

So long as CMS employs a “pay and chase” method of reimbursement, audits will be a permanent part of the healthcare landscape. Every medical practice should consult with an attorney experienced in handling Medicare, Medicaid and other third party audits in order to develop effective policies and procedures. By preparing for an audit prior to its occurrence a practice is in the best position to avoid any kind of sanction or overpayment demand.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you think cardiologist and cardiology practices are under a higher amount of scrutiny? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “Cardiologists Enmeshed in High-Scrutiny Climate.” Modern Healthcare. (July 8, 2013). From: http://www.modernhealthcare.com/article/20130708/BLOG/307089995/cardiologists-enmeshed-in-high-scrutiny-climate

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999. Copyright © 1996-2012 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:50-04:00June 1, 2018|Categories: Medicaid audit, Medicare Audit, The Health Law Firm Blog|Tags: cardiologist, cardiology, cardiology practice, cardiovascular care, Centers for Medicare and Medicaid Services (CMS), defense attorney, defense lawyer, medicare, medicare audit, Medicare audit attorney, Medicare audit lawyer, Medicare reimbursement, Medicare spending, overpayment, overpayment demand, physician, physician attorney, physician lawyer, practice audit, qui tam, RAC attorney, RAC Audits, RAC lawyer, Recovery Audit Contractor (RAC), the health law firm, whistleblowers, Zone Program Integrity Contractors (ZPIC), ZPIC attorney, ZPIC Audits, ZPIC lawyer, ZPIC site visits|Comments Off