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Archive for May, 2011

Audits Are Increasing “Thanks” to New Healthcare Laws

Wednesday, May 25th, 2011

Hospitals and physicians are experiencing a great number of audits due to new reform laws that hope to reduce healthcare fraud, waste, and abuse. The most recognizable type of audit – RAC (Recovery Audit Contractors) are paid on a contingency basis – meaning they do not get paid unless they discover the hospital or the specific provider is billing incorrectly or other audit rules that may apply.

What you may not know is that the government has MULTIPLE types of audit programs out there looking into hospitals, home health agencies, individual providers, and DME (durable medical equipment) companies in order to decrease reimbursement for coding issues, lack of documentation, and inaccurate documentation among many other things.

What types of audits should you be prepared for?

  • MAC (Medicare Administrative Contractor)

o   Compliance with ADMINISTRATIVE COSTS

  • PSC (Program Safeguard Contractor)

o   Looking for FRAUD, WASTE, & ABUSE

  • ZPIC (Zone Program Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • MEDIC (Medicare Drug Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • RVC (Recovery Audit Validation Contractors)

o   Looking for OVERPAYMENTS

  • QIC (Qualified Independent Contractors)

o   Compliance with ADMINISTRATIVE COSTS

  • MIC (Medicaid Integrity Contractors)

o   Compliance with PROGRAM INTEGRITY

Why is this happening?

According to the “Summary of the 2008 Financial Report of the United States Government,” in 2008, Medicare hospital insurance benefits began to exceed program tax revenues.

The bottom line is there is not enough money. Private insurance companies are following suit – the application of contractor audit methods are being applied RIGHT now.

Remember, it is not about preparing for any particular “audit” program – it is about developing internal controls, effective mitigation strategies, and an effective response to any third party.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Patient Advocacy – More Tips on How to Be an Empowered Patient

Wednesday, May 18th, 2011

What can you do if a doctor refuses to treat you as a patient?

First of all, if a doctor doesn’t want to treat you, is that the type of person you want in charge of your health? Probably not, so the best tip is to find a new doctor.

However, if you believe that this doctor is the only doctor in your area that can treat your disease, or you have heard such marvelous things about this doctor and you can’t give up just yet, you have a couple of options.

1.       File a complaint with the State. You can report the doctor to the State for refusing to treat you. You should be weary though, this will not likely result in any disciplinary action unless the doctor has discriminated against you due to sex or race.

2.       Report the doctor to the insurer. If you report the doctor to the insurer, the insurer might investigate and warn the doctor or even drop the doctor from its plan. Once again, this is unlikely unless there is some sort of discrimination attached.

Overall, patients should be careful when pursuing this avenue. If word gets around that you’re complaining about doctors, less and less doctors might be less willing to take you as a patient.

What is the “fail first” medication policy some insurers use?

Many insurers require the least expensive medication or treatments be exhausted first before they are willing to shell out more money for the more expensive medications and treatments. This might make sense, but many times, the less expensive medications and treatments do not work, wasting a patient’s time and resources before they can receive the drug they need to heal.

Advocates in New York are trying to stop this practice saying it puts the patient through unnecessary pain and suffering.

Is your insurer doing this to you? Write your Congressmen, join an advocacy, and spread the word that this is happening.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Medical Identity Theft: What is it? How does it happen? How can it affect you or your loved ones?

Friday, May 13th, 2011

Some stats for thought:

  • As many as 500,000 Americans have been victims of medical identify theft, according to the World Privacy Forum.
  • At one medical clinic in Weston, Florida, a front desk clerk downloaded information of more than 1,100 Medicare patients and gave it to a cousin who made $2.8 million in false Medicare claims.
  • Thieves use your identity to buy prescription drugs. They then sell these prescriptions or use them to feed their own addictions.

What does this mean to the average person?

If you find yourself being a victim of medical identity theft, you might receive hospital bills in the mail for services you never received. You might visit an area hospital only to find your records include false or wrong information, like blood type or previous surgeries you’ve never received. You could even have your kids taken away like this unassuming woman almost did during her ordeal with medical identity theft.

Anndorie Sachs, a mother of four from Salt Lake City, has always considered herself a loving, caring mom.  So one can imagine her surprise when a state social worker called Sachs and accused her of having given birth to a baby girl with methamphetamines in her system and abandoning her in the hospital.

Even more unthinkable, according to Sachs, the state told her over the phone she was an unfit mother, and planned to take custody of all her kids.  “I definitely went into shock,” she says.  But, Sachs hadn’t given birth to a baby with meth in its system. In fact, she hadn’t given birth in two years.  Anndorie Sachs was a victim of medical identity theft.”

How can you avoid becoming a victim?

If you don’t monitor your EOBs fraudsters have a better chance of stealing your Medical Identity. This can cause both financial and physical harm – if someone else’s information is included in your medical record you could receive false diagnoses. Take ownership of your healthcare finances and request your medical records and bills once a year.

If your wallet is stolen, notify your insurance company — not just credit-card companies — because your benefit card is like a credit card without a limit.

Be an empowered patient and take charge of your health and healthcare finances.

Thanks for reading!

Your healthcare resource – Rebecca Busch