Following concerns raised by the ACC and others, the Centers for Medicare and Medicaid Services (CMS) has announced the delay of two of the three new demonstration programs aimed at eliminating improper payments. All three programs were slated to take effect on Jan. 1.
Of the two programs that were delayed, the first requiring prior authorization for power wheelchairs, will not affect cardiologists. However, this is the first time the Medicare program is requiring prior authorization for any service and could lead to future prior authorization requirements for other services. As such, the ACC will continue to monitor this program carefully.
The second program, called the Recovery Audit Prepayment Review demonstration, requires Recovery Audit Contractors (RACs) to conduct reviews of claims before they are paid for specified DRGs in 11 states (CA, FL, IL, LA, MI, MO, NY, NC, OH, PA and TX). Initially, the RACs will review inpatient short stay claims because CMS audit programs have indicated that there are high rates of error for these claims. CMS has selected specific DRGs for review and will implement them slowly. The first DRG selected for review is for MS-DRG 312 – Syncope and Collapse, followed by the addition of MS-DRG 069 – Transient Ischemia . The RACs will add DRGs for gastrointestinal care and diabetes later in the year. CMS expects to review up to 100,000 claims each year through this program. The ACC raised serious concerns both verbally and written regarding this program and CMS has agree to delay implementation while staff review these concerns.
The third program, which did take effect on Jan. 1, may have an indirect effect on cardiovascular care. Organizations that choose to participate in this program will be permitted to rebill for services that should have been provided in the outpatient setting but were billed as inpatient short stay claims and were denied on the basis that the inpatient admission was not reasonable and necessary. In exchange for receiving 90 percent of the Medicare Part B allowed amount, these organizations will give up their right to appeal these decisions and to charge beneficiaries for additional co-pay or out-of-pocket costs.
The ACC will continue to monitor all of these programs. In addition, the College is developing a resource center that will be available on Feb. 1 to help providers understand coding, billing and compliance issues, as well as stay on top of programs such as these.