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Caught in the crosshairs

By Chris Anderson

ORLANDO, FL – The Florida Chapter of the American College of Cardiology (ACC) has been taken up a fight against Medicare pre-payment audits first announced by the state's Medicare Administrative Contractor, Jacksonville, Fla.-based First Coast Service Options.

Originally set to begin Jan. 1, as a program of 100 percent pre-payment audits on 15 specific DRGs (11 involving cardiac procedures) identified by CMS as having high payment error rates. After objections from the Florida Chapter, the program was both delayed until Feb 1. and will now only involve 30 percent of the Part A claims received by FCSO.

The audits will only apply to Medicare Part A payments to hospitals, though doctors paid for the services under Medicare Part B would need to pay back any money they had received for a Part A claim that was rejected for payment.

According to Juan Aranda, Jr., MD, president of the Florida Chapter ACC, auditors will be paying special attention to patient status when determining eligibility for payment, based on communication with Jim Corcoran, medical director of FCSO.

"Distinction between inpatient and outpatient hospitalization is crucial," Aranda said. "If a scheduled elective cardiac procedure is maintained as an outpatient stay, it will not be audited."

While the delay and the reduction of the total number of audits may be a victory, it is only a small one. Jerold Saef, MD, assistant chief of Cardiology at Bay Pines VA Hospital in Bay Pines, Fla., and chair of the Florida Chapter ACC Third Party Reimbursement Committee thinks the pre-payment audits are overreaching.

"I think the lessons that CMS wants to teach are obscure," said Saef. "Their lessons on documentation have to do with policies that were written in the 1980s, and the difference between inpatient and outpatient makes sense to them but it seems ridiculous on the provision of care."

Saef maintains CMS guidelines for when an inpatient stay is necessary versus outpatient care are confusing at best. Further, hospitals subject to this scrutiny are at the mercy of the doctors understanding these rules, since only doctors can make the decision whether to admit a patient or not.

The national office of ACC has been monitoring the situation and says it understands the motivation at CMS to reduce payment rate errors. But there are disagreements about how, exactly, CMS should go about this.

"We have some concerns about these programs that seem to approach reducing the improper payment rate from a penalty perspective versus an education perspective," said Lisa Goldstein, associate director of regulatory affairs at Washington, D.C.-based ACC. "Withholding and delaying payment can cause cash flow problems, which can interfere with the ability of the doctors and hospitals to provide healthcare services."

ACC officials said their understanding is the program will be introduced in other states that have also shown high error rates, though they were not aware of other programs currently underway.

Officials from CMS would not comment on the story and a request for an interview from FCSO was declined by a public relations official who noted in an email that "this initiative is a federal-level program, and we have been advised by CMS that any media requests for information about this topic be referred to the CMS press office."