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Recovery Audit Contractor Program Is Underway
WASHINGTON Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country this summer, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006 by the Tax Relief and Healthcare Act. It is administered by private contractors who collect a fee based on the errors they detect.
The RACswhich have access to Medicare fee-for-service claims datause software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated "complex reviews" on diagnosis-related group (DRG) coding errors, according to Cmdr. Marie Casey, USPHS, CMS deputy director of recovery audit operations. And by 2010, in addition to these audits, the RACs will also review the medical necessity of certain claims. These types of reviews will rely on the expert medical opinion of physicians and other medical professionals who work for the RACs. Cmdr. Casey added that the RACs can audit any Medicare fee-for-service claims up to 3 years from the payment date, but during the program's early phase will review only claims made on or after Oct. 1, 2007.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that you can avoid making the same mistakes.
▸ "Keep a clean shop," Lt. Lew advised. "Make sure that you're in compliance with all the applicable Medicare policies, coverage deter-minations, coding directives, requirements for documentation."
▸ Identify key RAC contacts. Each region has its own RAC. (See box.)
▸ Develop processes for tracking and responding to RAC requests and demand letters. "There are timelines attached to demand letters," Lt. Lew said.
▸ Appeal when necessary. "If you make a business decision that an appeal is warranted, we would certainly encourage you to appeal," Lt. Lew said.
For more information, visit www.cms.hhs.gov/RAC
Source ELSEVIER GLOBAL MEDICAL NEWS
Get Ready for the RAC
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before an RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic "black and white" reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Starting as early as September, the RACs may begin reviewing coding issues and diagnosis-related group validations, which will require the review of additional documentation.
Once the RAC has been established in the region, the RAC may begin to review claims for medical necessity.
To contact the RAC for your region:
▸ Region A: Diversified Collection Services (DCS), 1-866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 1-866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
WASHINGTON Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country this summer, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006 by the Tax Relief and Healthcare Act. It is administered by private contractors who collect a fee based on the errors they detect.
The RACswhich have access to Medicare fee-for-service claims datause software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated "complex reviews" on diagnosis-related group (DRG) coding errors, according to Cmdr. Marie Casey, USPHS, CMS deputy director of recovery audit operations. And by 2010, in addition to these audits, the RACs will also review the medical necessity of certain claims. These types of reviews will rely on the expert medical opinion of physicians and other medical professionals who work for the RACs. Cmdr. Casey added that the RACs can audit any Medicare fee-for-service claims up to 3 years from the payment date, but during the program's early phase will review only claims made on or after Oct. 1, 2007.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that you can avoid making the same mistakes.
▸ "Keep a clean shop," Lt. Lew advised. "Make sure that you're in compliance with all the applicable Medicare policies, coverage deter-minations, coding directives, requirements for documentation."
▸ Identify key RAC contacts. Each region has its own RAC. (See box.)
▸ Develop processes for tracking and responding to RAC requests and demand letters. "There are timelines attached to demand letters," Lt. Lew said.
▸ Appeal when necessary. "If you make a business decision that an appeal is warranted, we would certainly encourage you to appeal," Lt. Lew said.
For more information, visit www.cms.hhs.gov/RAC
Source ELSEVIER GLOBAL MEDICAL NEWS
Get Ready for the RAC
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before an RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic "black and white" reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Starting as early as September, the RACs may begin reviewing coding issues and diagnosis-related group validations, which will require the review of additional documentation.
Once the RAC has been established in the region, the RAC may begin to review claims for medical necessity.
To contact the RAC for your region:
▸ Region A: Diversified Collection Services (DCS), 1-866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 1-866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
WASHINGTON Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country this summer, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006 by the Tax Relief and Healthcare Act. It is administered by private contractors who collect a fee based on the errors they detect.
The RACswhich have access to Medicare fee-for-service claims datause software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated "complex reviews" on diagnosis-related group (DRG) coding errors, according to Cmdr. Marie Casey, USPHS, CMS deputy director of recovery audit operations. And by 2010, in addition to these audits, the RACs will also review the medical necessity of certain claims. These types of reviews will rely on the expert medical opinion of physicians and other medical professionals who work for the RACs. Cmdr. Casey added that the RACs can audit any Medicare fee-for-service claims up to 3 years from the payment date, but during the program's early phase will review only claims made on or after Oct. 1, 2007.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that you can avoid making the same mistakes.
▸ "Keep a clean shop," Lt. Lew advised. "Make sure that you're in compliance with all the applicable Medicare policies, coverage deter-minations, coding directives, requirements for documentation."
▸ Identify key RAC contacts. Each region has its own RAC. (See box.)
▸ Develop processes for tracking and responding to RAC requests and demand letters. "There are timelines attached to demand letters," Lt. Lew said.
▸ Appeal when necessary. "If you make a business decision that an appeal is warranted, we would certainly encourage you to appeal," Lt. Lew said.
For more information, visit www.cms.hhs.gov/RAC
Source ELSEVIER GLOBAL MEDICAL NEWS
Get Ready for the RAC
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before an RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic "black and white" reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Starting as early as September, the RACs may begin reviewing coding issues and diagnosis-related group validations, which will require the review of additional documentation.
Once the RAC has been established in the region, the RAC may begin to review claims for medical necessity.
To contact the RAC for your region:
▸ Region A: Diversified Collection Services (DCS), 1-866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 1-866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
Insured Patients Pay a Premium for the Uninsured
WASHINGTON — The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
That is the hidden health tax,” said the group's executive director, Ron Pollack. “Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is.”
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, $116 billion of care from hospitals, doctors, and other health care professionals was provided to the uninsured last year. Of this, 37% was paid for out of pocket by the patients themselves. An additional 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder—$42.7 billion—was unpaid.
“Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance,” according to the report. “This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure.”
At a press conference to release the report, Ron Williams, the chairman and chief executive officer of Aetna Inc., said that the report answers a question many consumers have, “which is, 'why does my premium go up?'”
He added, “For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net.”
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care, and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee and a leader on health care reform, said, “As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year.”
WASHINGTON — The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
That is the hidden health tax,” said the group's executive director, Ron Pollack. “Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is.”
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, $116 billion of care from hospitals, doctors, and other health care professionals was provided to the uninsured last year. Of this, 37% was paid for out of pocket by the patients themselves. An additional 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder—$42.7 billion—was unpaid.
“Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance,” according to the report. “This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure.”
At a press conference to release the report, Ron Williams, the chairman and chief executive officer of Aetna Inc., said that the report answers a question many consumers have, “which is, 'why does my premium go up?'”
He added, “For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net.”
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care, and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee and a leader on health care reform, said, “As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year.”
WASHINGTON — The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
That is the hidden health tax,” said the group's executive director, Ron Pollack. “Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is.”
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, $116 billion of care from hospitals, doctors, and other health care professionals was provided to the uninsured last year. Of this, 37% was paid for out of pocket by the patients themselves. An additional 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder—$42.7 billion—was unpaid.
“Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance,” according to the report. “This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure.”
At a press conference to release the report, Ron Williams, the chairman and chief executive officer of Aetna Inc., said that the report answers a question many consumers have, “which is, 'why does my premium go up?'”
He added, “For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net.”
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care, and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee and a leader on health care reform, said, “As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year.”
Call for School Mandate to Aid HPV Vaccination
BALTIMORE — The notion that the future burden of human papillomavirus will be greatly decreased thanks to the HPV vaccine may be unrealistic without a national school mandate, according to a new model.
That's because voluntary vaccination among the target population of 11- to 17-year-old girls so far has been modest, with just 7% of this cohort receiving all three doses in the first year of the vaccine's availability, according to Dr. Amanda Dempsey of the University of Michigan, Ann Arbor.
“Under no-mandate conditions, our model suggests that vaccine utilization may be suboptimal and that coverage of even 70% could take decades to achieve,” Dr. Dempsey and David Mendez, Ph.D., also of the university, wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.
The researchers created a model of HPV vaccine uptake among 11- to 17-year-old girls based on census data, published literature on parental attitudes toward HPV vaccination, adolescent health care utilization patterns, and expert physician opinion. The model assumed that a school mandate would be applied on a national level, and would be such that vaccination would be required for school attendance, with exceptions similar to those of other vaccine mandates.
They adjusted their model to accurately predict the numbers reported by the Centers for Disease Control and Prevention during the first year of the vaccine's availability: 25% of U.S. 11- to 17-year-old girls received the first dose, 17% received the first and second dose, and 7% received all three recommended doses of the vaccine.
Without a mandate in place, the authors predicted that 70% utilization of the vaccine would be reached by year 23 of its availability, or 2030. Under that model, by year 50 (in 2057) just 78% of the cohort will have received all three doses, they predicted. With a mandate, 70% of the 11- to 17-year-old cohort would be vaccinated with all three doses by year 8 (in 2015). At year 41 (by 2048), 90% would be vaccinated.
In an interview, Dr. Dempsey added that she and Dr. Mendez did not account for vaccination of other groups, including those aged 18–26 years.
Dr. Dempsey said that at the time the study was done and at the time of its presentation, she had no ties to the pharmaceutical industry. However, shortly after the conclusion of the PAS meeting, she said she agreed to serve on a Merck & Co. advisory board for male HPV vaccination.
BALTIMORE — The notion that the future burden of human papillomavirus will be greatly decreased thanks to the HPV vaccine may be unrealistic without a national school mandate, according to a new model.
That's because voluntary vaccination among the target population of 11- to 17-year-old girls so far has been modest, with just 7% of this cohort receiving all three doses in the first year of the vaccine's availability, according to Dr. Amanda Dempsey of the University of Michigan, Ann Arbor.
“Under no-mandate conditions, our model suggests that vaccine utilization may be suboptimal and that coverage of even 70% could take decades to achieve,” Dr. Dempsey and David Mendez, Ph.D., also of the university, wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.
The researchers created a model of HPV vaccine uptake among 11- to 17-year-old girls based on census data, published literature on parental attitudes toward HPV vaccination, adolescent health care utilization patterns, and expert physician opinion. The model assumed that a school mandate would be applied on a national level, and would be such that vaccination would be required for school attendance, with exceptions similar to those of other vaccine mandates.
They adjusted their model to accurately predict the numbers reported by the Centers for Disease Control and Prevention during the first year of the vaccine's availability: 25% of U.S. 11- to 17-year-old girls received the first dose, 17% received the first and second dose, and 7% received all three recommended doses of the vaccine.
Without a mandate in place, the authors predicted that 70% utilization of the vaccine would be reached by year 23 of its availability, or 2030. Under that model, by year 50 (in 2057) just 78% of the cohort will have received all three doses, they predicted. With a mandate, 70% of the 11- to 17-year-old cohort would be vaccinated with all three doses by year 8 (in 2015). At year 41 (by 2048), 90% would be vaccinated.
In an interview, Dr. Dempsey added that she and Dr. Mendez did not account for vaccination of other groups, including those aged 18–26 years.
Dr. Dempsey said that at the time the study was done and at the time of its presentation, she had no ties to the pharmaceutical industry. However, shortly after the conclusion of the PAS meeting, she said she agreed to serve on a Merck & Co. advisory board for male HPV vaccination.
BALTIMORE — The notion that the future burden of human papillomavirus will be greatly decreased thanks to the HPV vaccine may be unrealistic without a national school mandate, according to a new model.
That's because voluntary vaccination among the target population of 11- to 17-year-old girls so far has been modest, with just 7% of this cohort receiving all three doses in the first year of the vaccine's availability, according to Dr. Amanda Dempsey of the University of Michigan, Ann Arbor.
“Under no-mandate conditions, our model suggests that vaccine utilization may be suboptimal and that coverage of even 70% could take decades to achieve,” Dr. Dempsey and David Mendez, Ph.D., also of the university, wrote in a poster presented at the annual meeting of the Pediatric Academic Societies.
The researchers created a model of HPV vaccine uptake among 11- to 17-year-old girls based on census data, published literature on parental attitudes toward HPV vaccination, adolescent health care utilization patterns, and expert physician opinion. The model assumed that a school mandate would be applied on a national level, and would be such that vaccination would be required for school attendance, with exceptions similar to those of other vaccine mandates.
They adjusted their model to accurately predict the numbers reported by the Centers for Disease Control and Prevention during the first year of the vaccine's availability: 25% of U.S. 11- to 17-year-old girls received the first dose, 17% received the first and second dose, and 7% received all three recommended doses of the vaccine.
Without a mandate in place, the authors predicted that 70% utilization of the vaccine would be reached by year 23 of its availability, or 2030. Under that model, by year 50 (in 2057) just 78% of the cohort will have received all three doses, they predicted. With a mandate, 70% of the 11- to 17-year-old cohort would be vaccinated with all three doses by year 8 (in 2015). At year 41 (by 2048), 90% would be vaccinated.
In an interview, Dr. Dempsey added that she and Dr. Mendez did not account for vaccination of other groups, including those aged 18–26 years.
Dr. Dempsey said that at the time the study was done and at the time of its presentation, she had no ties to the pharmaceutical industry. However, shortly after the conclusion of the PAS meeting, she said she agreed to serve on a Merck & Co. advisory board for male HPV vaccination.
Intervention Doubles Flu Vaccinations in 1 Year
BALTIMORE — A three-pronged intervention to increase influenza vaccination rates in high-risk pediatric patients doubled the number of patients who were vaccinated in just 1 year.
Some of the lessons learned: Start planning for flu season long before it actually begins, and be creative with scheduling to allow for weekend and evening hours, Dr. Zeina M. Samaan said at the annual meeting of the Pediatric Academic Societies.
Dr. Samaan, a pediatrician at Cincinnati Children's Hospital Medical Center, said that before intervention, in the 2006–2007 flu season, 72% of the asthma patients and 68% of the children aged 6–59 months old who were seen at an inner city pediatric primary care clinic received an influenza immunization.
After intervention, in the 2007–2008 flu season, 84% of the asthma target population was immunized, as were 89% of patients aged 6–59 months. Those rates stayed about the same during the 2008–2009 flu season.
In total, in 2009, 2,203 asthma patients and 4,665 patients aged 6–59 months were vaccinated. In contrast, in 2007, there were 1,120 asthma patients and 1,760 patients aged 6–59 months who were vaccinated.
The interventions fell into three general categories, according to Dr. Samaan.
The first tactic was to increase access for patients. “Throughout the flu season, from October through March, we had—every day—30 appointments for a flu shot, only offered as a nurse visit,” said Dr. Samaan. “And even though the majority of our visits are by appointment, we also accommodated those patients who walked in our clinic and asked for a flu vaccine.” The practice also organized a walk-in flu shot clinic every Saturday throughout the flu season.
“We also trained our … staff to register and immunize siblings,” she added.
The second part of the intervention involved clinical decision support. Using the electronic health records system that has been in place at her practice for about 5 years, Dr. Samaan and her staff programmed the computers—which are located in every exam room—to automatically open a reminder window. “When a patient comes in and meets the criteria for a flu vaccine, an alert will fire,” she said.
Additionally, on every visit, when the triage nurse triaged the patient, the nurse was trained to ask whether the patient had received the flu vaccine. If the patient hadn't been vaccinated, the nurse would offer the vaccine, and document whether the patient got the vaccine or refused it. “So when the physicians opened the chart, [if the patient had refused the vaccine], they would see it on the chief complaint, and be reminded to offer it [again],” said Dr. Samaan. The staff also was trained to request a flu shot if the provider forgot to order it.
The third portion of the intervention involved patient education. Previously, Dr. Samaan's clinic had sent out postcard reminders to patients about flu vaccine at the start of the season, “and we'd get half of them returned with the wrong address,” she said. This year, thanks to some early planning, “when the families came in for a visit a few months before the flu season started, we gave them a flu reminder card, and asked them to fill it with the most recent address or the best address at which we could reach them.” When the season began, the practice mailed the cards, “and we had very few returned to us this year with the wrong address.”
Posters about the flu vaccine were hung in the waiting room and exam rooms, as well as in the physician break rooms and even the bathrooms.
Finally, the staff also attended bimonthly meetings with other outpatient clinics in the area to “learn about strategies and share ideas and experiences,” she said.
Although the clinic fell short of its goal to immunize 95% of the high-risk patients, the intervention was relatively cheap, with the greatest expense being staffing at the Saturday clinics for the “huge number” of patients who showed up. Her staff is already working on techniques to further increase rates this 2009–2010 flu season, she said.
Dr. Samaan said that she had no conflicts of interest to disclose.
BALTIMORE — A three-pronged intervention to increase influenza vaccination rates in high-risk pediatric patients doubled the number of patients who were vaccinated in just 1 year.
Some of the lessons learned: Start planning for flu season long before it actually begins, and be creative with scheduling to allow for weekend and evening hours, Dr. Zeina M. Samaan said at the annual meeting of the Pediatric Academic Societies.
Dr. Samaan, a pediatrician at Cincinnati Children's Hospital Medical Center, said that before intervention, in the 2006–2007 flu season, 72% of the asthma patients and 68% of the children aged 6–59 months old who were seen at an inner city pediatric primary care clinic received an influenza immunization.
After intervention, in the 2007–2008 flu season, 84% of the asthma target population was immunized, as were 89% of patients aged 6–59 months. Those rates stayed about the same during the 2008–2009 flu season.
In total, in 2009, 2,203 asthma patients and 4,665 patients aged 6–59 months were vaccinated. In contrast, in 2007, there were 1,120 asthma patients and 1,760 patients aged 6–59 months who were vaccinated.
The interventions fell into three general categories, according to Dr. Samaan.
The first tactic was to increase access for patients. “Throughout the flu season, from October through March, we had—every day—30 appointments for a flu shot, only offered as a nurse visit,” said Dr. Samaan. “And even though the majority of our visits are by appointment, we also accommodated those patients who walked in our clinic and asked for a flu vaccine.” The practice also organized a walk-in flu shot clinic every Saturday throughout the flu season.
“We also trained our … staff to register and immunize siblings,” she added.
The second part of the intervention involved clinical decision support. Using the electronic health records system that has been in place at her practice for about 5 years, Dr. Samaan and her staff programmed the computers—which are located in every exam room—to automatically open a reminder window. “When a patient comes in and meets the criteria for a flu vaccine, an alert will fire,” she said.
Additionally, on every visit, when the triage nurse triaged the patient, the nurse was trained to ask whether the patient had received the flu vaccine. If the patient hadn't been vaccinated, the nurse would offer the vaccine, and document whether the patient got the vaccine or refused it. “So when the physicians opened the chart, [if the patient had refused the vaccine], they would see it on the chief complaint, and be reminded to offer it [again],” said Dr. Samaan. The staff also was trained to request a flu shot if the provider forgot to order it.
The third portion of the intervention involved patient education. Previously, Dr. Samaan's clinic had sent out postcard reminders to patients about flu vaccine at the start of the season, “and we'd get half of them returned with the wrong address,” she said. This year, thanks to some early planning, “when the families came in for a visit a few months before the flu season started, we gave them a flu reminder card, and asked them to fill it with the most recent address or the best address at which we could reach them.” When the season began, the practice mailed the cards, “and we had very few returned to us this year with the wrong address.”
Posters about the flu vaccine were hung in the waiting room and exam rooms, as well as in the physician break rooms and even the bathrooms.
Finally, the staff also attended bimonthly meetings with other outpatient clinics in the area to “learn about strategies and share ideas and experiences,” she said.
Although the clinic fell short of its goal to immunize 95% of the high-risk patients, the intervention was relatively cheap, with the greatest expense being staffing at the Saturday clinics for the “huge number” of patients who showed up. Her staff is already working on techniques to further increase rates this 2009–2010 flu season, she said.
Dr. Samaan said that she had no conflicts of interest to disclose.
BALTIMORE — A three-pronged intervention to increase influenza vaccination rates in high-risk pediatric patients doubled the number of patients who were vaccinated in just 1 year.
Some of the lessons learned: Start planning for flu season long before it actually begins, and be creative with scheduling to allow for weekend and evening hours, Dr. Zeina M. Samaan said at the annual meeting of the Pediatric Academic Societies.
Dr. Samaan, a pediatrician at Cincinnati Children's Hospital Medical Center, said that before intervention, in the 2006–2007 flu season, 72% of the asthma patients and 68% of the children aged 6–59 months old who were seen at an inner city pediatric primary care clinic received an influenza immunization.
After intervention, in the 2007–2008 flu season, 84% of the asthma target population was immunized, as were 89% of patients aged 6–59 months. Those rates stayed about the same during the 2008–2009 flu season.
In total, in 2009, 2,203 asthma patients and 4,665 patients aged 6–59 months were vaccinated. In contrast, in 2007, there were 1,120 asthma patients and 1,760 patients aged 6–59 months who were vaccinated.
The interventions fell into three general categories, according to Dr. Samaan.
The first tactic was to increase access for patients. “Throughout the flu season, from October through March, we had—every day—30 appointments for a flu shot, only offered as a nurse visit,” said Dr. Samaan. “And even though the majority of our visits are by appointment, we also accommodated those patients who walked in our clinic and asked for a flu vaccine.” The practice also organized a walk-in flu shot clinic every Saturday throughout the flu season.
“We also trained our … staff to register and immunize siblings,” she added.
The second part of the intervention involved clinical decision support. Using the electronic health records system that has been in place at her practice for about 5 years, Dr. Samaan and her staff programmed the computers—which are located in every exam room—to automatically open a reminder window. “When a patient comes in and meets the criteria for a flu vaccine, an alert will fire,” she said.
Additionally, on every visit, when the triage nurse triaged the patient, the nurse was trained to ask whether the patient had received the flu vaccine. If the patient hadn't been vaccinated, the nurse would offer the vaccine, and document whether the patient got the vaccine or refused it. “So when the physicians opened the chart, [if the patient had refused the vaccine], they would see it on the chief complaint, and be reminded to offer it [again],” said Dr. Samaan. The staff also was trained to request a flu shot if the provider forgot to order it.
The third portion of the intervention involved patient education. Previously, Dr. Samaan's clinic had sent out postcard reminders to patients about flu vaccine at the start of the season, “and we'd get half of them returned with the wrong address,” she said. This year, thanks to some early planning, “when the families came in for a visit a few months before the flu season started, we gave them a flu reminder card, and asked them to fill it with the most recent address or the best address at which we could reach them.” When the season began, the practice mailed the cards, “and we had very few returned to us this year with the wrong address.”
Posters about the flu vaccine were hung in the waiting room and exam rooms, as well as in the physician break rooms and even the bathrooms.
Finally, the staff also attended bimonthly meetings with other outpatient clinics in the area to “learn about strategies and share ideas and experiences,” she said.
Although the clinic fell short of its goal to immunize 95% of the high-risk patients, the intervention was relatively cheap, with the greatest expense being staffing at the Saturday clinics for the “huge number” of patients who showed up. Her staff is already working on techniques to further increase rates this 2009–2010 flu season, she said.
Dr. Samaan said that she had no conflicts of interest to disclose.
MD Shortage Calls for Multipronged Approach
WASHINGTON — The United States will be short 159,300 physicians by 2025. And while increasing medical school enrollment will help, there's no way that 159,000 more physicians can be minted in 15 years.
That's according to Edward Salsberg, director of the Center for Health Workforce Studies at the University of Albany, School of Public Health. The stark figure comes from a 2008 report from the center.
“We need to look at how we design the delivery system. We need to promote interdisciplinary teams and integrated delivery systems,” Mr. Salsberg said at a physician workforce research conference, sponsored by the Association of American Medical Colleges.
About 26,000 students enter medical school each year, said Mr. Salsberg. But according to the American Medical Association, in 2007, about 13,000 currently active physicians reached age 63 years, and presumably at least began to think about retirement.
Indeed, many of these will likely forestall retirement for at least a few years, especially given the current economy. But in a few years, “we're going to find ourselves with literally tens of thousands of physicians who [are] waiting to retire,” Mr. Salsberg predicted.
Add those to the 24,000 active physicians set to reach age 63 in 2017, plus the increased demand that health reform and the aging population both promise, and a true shortage emerges—not only in primary care, but also in general surgery, psychology, cardiology, and other specialties.
“Is it a question of reforming the health care system, redesigning the health care system, or adding more physicians and other health care professionals? And it's really not a question of either or, it's a question of how do we do both simultaneously.”
AAMC-supported legislation has been introduced in the Senate to address the situation—the Resident Physician Shortage Reduction Act of 2009 (S. 973), sponsored by Sen. Bill Nelson (D-Fla.). If passed, it would increase the number of Medicare-supported training positions for medical residents by 15%, or by about 15,000 slots. At press time, the bill had been referred to the Finance Committee.
WASHINGTON — The United States will be short 159,300 physicians by 2025. And while increasing medical school enrollment will help, there's no way that 159,000 more physicians can be minted in 15 years.
That's according to Edward Salsberg, director of the Center for Health Workforce Studies at the University of Albany, School of Public Health. The stark figure comes from a 2008 report from the center.
“We need to look at how we design the delivery system. We need to promote interdisciplinary teams and integrated delivery systems,” Mr. Salsberg said at a physician workforce research conference, sponsored by the Association of American Medical Colleges.
About 26,000 students enter medical school each year, said Mr. Salsberg. But according to the American Medical Association, in 2007, about 13,000 currently active physicians reached age 63 years, and presumably at least began to think about retirement.
Indeed, many of these will likely forestall retirement for at least a few years, especially given the current economy. But in a few years, “we're going to find ourselves with literally tens of thousands of physicians who [are] waiting to retire,” Mr. Salsberg predicted.
Add those to the 24,000 active physicians set to reach age 63 in 2017, plus the increased demand that health reform and the aging population both promise, and a true shortage emerges—not only in primary care, but also in general surgery, psychology, cardiology, and other specialties.
“Is it a question of reforming the health care system, redesigning the health care system, or adding more physicians and other health care professionals? And it's really not a question of either or, it's a question of how do we do both simultaneously.”
AAMC-supported legislation has been introduced in the Senate to address the situation—the Resident Physician Shortage Reduction Act of 2009 (S. 973), sponsored by Sen. Bill Nelson (D-Fla.). If passed, it would increase the number of Medicare-supported training positions for medical residents by 15%, or by about 15,000 slots. At press time, the bill had been referred to the Finance Committee.
WASHINGTON — The United States will be short 159,300 physicians by 2025. And while increasing medical school enrollment will help, there's no way that 159,000 more physicians can be minted in 15 years.
That's according to Edward Salsberg, director of the Center for Health Workforce Studies at the University of Albany, School of Public Health. The stark figure comes from a 2008 report from the center.
“We need to look at how we design the delivery system. We need to promote interdisciplinary teams and integrated delivery systems,” Mr. Salsberg said at a physician workforce research conference, sponsored by the Association of American Medical Colleges.
About 26,000 students enter medical school each year, said Mr. Salsberg. But according to the American Medical Association, in 2007, about 13,000 currently active physicians reached age 63 years, and presumably at least began to think about retirement.
Indeed, many of these will likely forestall retirement for at least a few years, especially given the current economy. But in a few years, “we're going to find ourselves with literally tens of thousands of physicians who [are] waiting to retire,” Mr. Salsberg predicted.
Add those to the 24,000 active physicians set to reach age 63 in 2017, plus the increased demand that health reform and the aging population both promise, and a true shortage emerges—not only in primary care, but also in general surgery, psychology, cardiology, and other specialties.
“Is it a question of reforming the health care system, redesigning the health care system, or adding more physicians and other health care professionals? And it's really not a question of either or, it's a question of how do we do both simultaneously.”
AAMC-supported legislation has been introduced in the Senate to address the situation—the Resident Physician Shortage Reduction Act of 2009 (S. 973), sponsored by Sen. Bill Nelson (D-Fla.). If passed, it would increase the number of Medicare-supported training positions for medical residents by 15%, or by about 15,000 slots. At press time, the bill had been referred to the Finance Committee.
Recovery Audit Contractor Program Starts Soon
WASHINGTON — Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country later this summer, with demand letters reaching providers in August or early September, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006. It is administered by private contractors who collect a fee based on the errors they detect.
The RACs—which have access to Medicare fee-for-service claims data—use software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated “complex reviews” on diagnosis-related group (DRG) coding errors, according to Cmdr. Marie Casey, U.S. Public Health Service, CMS deputy director of recovery audit operations.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that your practice can avoid making the same mistakes. This information is available at www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
▸ “Keep a clean shop,” Lt. Lew advised. “Make sure that you're in compliance with all the applicable Medicare policies, coverage determinations, coding directives, requirements for documentation.”
▸ Identify key RAC contacts. Each region has its own RAC. (See box.)
▸ Develop processes for tracking and responding to RAC requests and demand letters. “There are timelines attached to demand letters,” Lt. Lew said. “You're going to want to have a system for tracking those timelines.”
For more information about the RAC program, visit www.cms.hhs.gov/RAC
Getting Ready for the RAC
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before a RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic “black and white” reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Once the RAC has been established in the region, it may begin to review claims for medical necessity.
To contact your regional RAC:
▸ Region A: Diversified Collection Services (DCS), 1-866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 1-866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
WASHINGTON — Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country later this summer, with demand letters reaching providers in August or early September, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006. It is administered by private contractors who collect a fee based on the errors they detect.
The RACs—which have access to Medicare fee-for-service claims data—use software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated “complex reviews” on diagnosis-related group (DRG) coding errors, according to Cmdr. Marie Casey, U.S. Public Health Service, CMS deputy director of recovery audit operations.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that your practice can avoid making the same mistakes. This information is available at www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
▸ “Keep a clean shop,” Lt. Lew advised. “Make sure that you're in compliance with all the applicable Medicare policies, coverage determinations, coding directives, requirements for documentation.”
▸ Identify key RAC contacts. Each region has its own RAC. (See box.)
▸ Develop processes for tracking and responding to RAC requests and demand letters. “There are timelines attached to demand letters,” Lt. Lew said. “You're going to want to have a system for tracking those timelines.”
For more information about the RAC program, visit www.cms.hhs.gov/RAC
Getting Ready for the RAC
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before a RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic “black and white” reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Once the RAC has been established in the region, it may begin to review claims for medical necessity.
To contact your regional RAC:
▸ Region A: Diversified Collection Services (DCS), 1-866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 1-866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
WASHINGTON — Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country later this summer, with demand letters reaching providers in August or early September, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006. It is administered by private contractors who collect a fee based on the errors they detect.
The RACs—which have access to Medicare fee-for-service claims data—use software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated “complex reviews” on diagnosis-related group (DRG) coding errors, according to Cmdr. Marie Casey, U.S. Public Health Service, CMS deputy director of recovery audit operations.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that your practice can avoid making the same mistakes. This information is available at www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
▸ “Keep a clean shop,” Lt. Lew advised. “Make sure that you're in compliance with all the applicable Medicare policies, coverage determinations, coding directives, requirements for documentation.”
▸ Identify key RAC contacts. Each region has its own RAC. (See box.)
▸ Develop processes for tracking and responding to RAC requests and demand letters. “There are timelines attached to demand letters,” Lt. Lew said. “You're going to want to have a system for tracking those timelines.”
For more information about the RAC program, visit www.cms.hhs.gov/RAC
Getting Ready for the RAC
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before a RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic “black and white” reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Once the RAC has been established in the region, it may begin to review claims for medical necessity.
To contact your regional RAC:
▸ Region A: Diversified Collection Services (DCS), 1-866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 1-866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
CT Scans Pose Risks for Pediatric Trauma Patients
BALTIMORE — CT scans are responsible for 91% of total radiation exposure in pediatric trauma patients, even though only 32% of imaging done in these patients is computed tomography, study results showed.
“If a patient is critical and the imaging study means the difference between life and death, then by all means get [the CT scan]. But there are times when imaging studies are done out of convenience or in place of other imaging modalities [like ultrasound] that could get pictures that are similar without radiation exposure,” said Dr. Marissa A. Brunetti, who is an intensivist at Johns Hopkins Hospital, Baltimore.
In a presentation at the annual meeting of the Pediatric Academic Societies, Dr. Brunetti reported on 729 patients aged 14 years and younger seen in the emergency department at her hospital over a 1-year period. Transfer patients were excluded from the analysis, as were any follow-up imaging studies. In total, 1,457 CT studies and 4,603 radiographic studies were conducted on these patients.
The average radiation dose for each patient was 12.8 millisieverts (mSv), with a high of 73.5 mSv. “The average dose from the environment is about 3 mSv per year, so that's more than four times the annual dose,” Dr. Brunetti said.
Stratified by type of injury, the 178 patients whose trauma resulted from a motor vehicle accident received the greatest radiation exposure, with an average of 18.6 mSv. Pedestrians struck by cars had the second highest level, at 15.6 mSv.
Part of the reason unnecessary imaging studies are done, she said, is that “pediatricians and providers don't know the doses that these images impart.” Education about which studies deliver the highest doses, and emphasis on keeping these studies to a minimum, could lower patients' total radiation exposure.
Another problem lies with transfer patients. Although the study did not look at transfers to the hospital, an audience member pointed out that “there is this idea that my CT scanner is going to be better than the CT that is done in the community hospital,” so patients wind up having studies repeated.
“Especially in the very young with long time horizons, the benefit of additional radiation exposure for diagnostic purposes should be weighed against the long-term risks of additional exposure,” Dr. Brunetti concluded. She had no disclosures in regard to this study.
BALTIMORE — CT scans are responsible for 91% of total radiation exposure in pediatric trauma patients, even though only 32% of imaging done in these patients is computed tomography, study results showed.
“If a patient is critical and the imaging study means the difference between life and death, then by all means get [the CT scan]. But there are times when imaging studies are done out of convenience or in place of other imaging modalities [like ultrasound] that could get pictures that are similar without radiation exposure,” said Dr. Marissa A. Brunetti, who is an intensivist at Johns Hopkins Hospital, Baltimore.
In a presentation at the annual meeting of the Pediatric Academic Societies, Dr. Brunetti reported on 729 patients aged 14 years and younger seen in the emergency department at her hospital over a 1-year period. Transfer patients were excluded from the analysis, as were any follow-up imaging studies. In total, 1,457 CT studies and 4,603 radiographic studies were conducted on these patients.
The average radiation dose for each patient was 12.8 millisieverts (mSv), with a high of 73.5 mSv. “The average dose from the environment is about 3 mSv per year, so that's more than four times the annual dose,” Dr. Brunetti said.
Stratified by type of injury, the 178 patients whose trauma resulted from a motor vehicle accident received the greatest radiation exposure, with an average of 18.6 mSv. Pedestrians struck by cars had the second highest level, at 15.6 mSv.
Part of the reason unnecessary imaging studies are done, she said, is that “pediatricians and providers don't know the doses that these images impart.” Education about which studies deliver the highest doses, and emphasis on keeping these studies to a minimum, could lower patients' total radiation exposure.
Another problem lies with transfer patients. Although the study did not look at transfers to the hospital, an audience member pointed out that “there is this idea that my CT scanner is going to be better than the CT that is done in the community hospital,” so patients wind up having studies repeated.
“Especially in the very young with long time horizons, the benefit of additional radiation exposure for diagnostic purposes should be weighed against the long-term risks of additional exposure,” Dr. Brunetti concluded. She had no disclosures in regard to this study.
BALTIMORE — CT scans are responsible for 91% of total radiation exposure in pediatric trauma patients, even though only 32% of imaging done in these patients is computed tomography, study results showed.
“If a patient is critical and the imaging study means the difference between life and death, then by all means get [the CT scan]. But there are times when imaging studies are done out of convenience or in place of other imaging modalities [like ultrasound] that could get pictures that are similar without radiation exposure,” said Dr. Marissa A. Brunetti, who is an intensivist at Johns Hopkins Hospital, Baltimore.
In a presentation at the annual meeting of the Pediatric Academic Societies, Dr. Brunetti reported on 729 patients aged 14 years and younger seen in the emergency department at her hospital over a 1-year period. Transfer patients were excluded from the analysis, as were any follow-up imaging studies. In total, 1,457 CT studies and 4,603 radiographic studies were conducted on these patients.
The average radiation dose for each patient was 12.8 millisieverts (mSv), with a high of 73.5 mSv. “The average dose from the environment is about 3 mSv per year, so that's more than four times the annual dose,” Dr. Brunetti said.
Stratified by type of injury, the 178 patients whose trauma resulted from a motor vehicle accident received the greatest radiation exposure, with an average of 18.6 mSv. Pedestrians struck by cars had the second highest level, at 15.6 mSv.
Part of the reason unnecessary imaging studies are done, she said, is that “pediatricians and providers don't know the doses that these images impart.” Education about which studies deliver the highest doses, and emphasis on keeping these studies to a minimum, could lower patients' total radiation exposure.
Another problem lies with transfer patients. Although the study did not look at transfers to the hospital, an audience member pointed out that “there is this idea that my CT scanner is going to be better than the CT that is done in the community hospital,” so patients wind up having studies repeated.
“Especially in the very young with long time horizons, the benefit of additional radiation exposure for diagnostic purposes should be weighed against the long-term risks of additional exposure,” Dr. Brunetti concluded. She had no disclosures in regard to this study.
Insured Patients Pay a Premium for the Uninsured
WASHINGTON — The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
“That is the hidden health tax,” said the group's executive director, Ron Pollack. “Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is.”
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, hospitals, doctors, and other health care professionals provided care worth $116 billion to the uninsured last year. Of this, 37% was paid out-of-pocket by the patients themselves.
A further 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder—$42.7 billion—was unpaid.
“Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance,” according to the report. “This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure.”
At a press briefing to release the report, Ron Williams, chairman and CEO of Aetna Inc., said that the report answers a question many consumers have, “which is, 'Why does my premium go up?'”
He added: “For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net.”
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee and a leader on health care reform, said, “As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year. We must repeal this hidden tax and lift the burden from American families and businesses by ensuring quality, affordable health care for all Americans.”
WASHINGTON — The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
“That is the hidden health tax,” said the group's executive director, Ron Pollack. “Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is.”
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, hospitals, doctors, and other health care professionals provided care worth $116 billion to the uninsured last year. Of this, 37% was paid out-of-pocket by the patients themselves.
A further 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder—$42.7 billion—was unpaid.
“Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance,” according to the report. “This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure.”
At a press briefing to release the report, Ron Williams, chairman and CEO of Aetna Inc., said that the report answers a question many consumers have, “which is, 'Why does my premium go up?'”
He added: “For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net.”
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee and a leader on health care reform, said, “As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year. We must repeal this hidden tax and lift the burden from American families and businesses by ensuring quality, affordable health care for all Americans.”
WASHINGTON — The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
“That is the hidden health tax,” said the group's executive director, Ron Pollack. “Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is.”
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, hospitals, doctors, and other health care professionals provided care worth $116 billion to the uninsured last year. Of this, 37% was paid out-of-pocket by the patients themselves.
A further 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder—$42.7 billion—was unpaid.
“Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance,” according to the report. “This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure.”
At a press briefing to release the report, Ron Williams, chairman and CEO of Aetna Inc., said that the report answers a question many consumers have, “which is, 'Why does my premium go up?'”
He added: “For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net.”
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee and a leader on health care reform, said, “As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year. We must repeal this hidden tax and lift the burden from American families and businesses by ensuring quality, affordable health care for all Americans.”
Medicare RAC Program Will Start This Summer
WASHINGTON — Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country later this summer, with demand letters reaching providers in August or early September, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006 by the Tax Relief and Healthcare Act. It is administered by private contractors who collect a fee based on the errors they detect.
The RACs—which have access to Medicare fee-for-service claims data—use software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated “complex reviews” on diagnosis-related group (DRG) coding errors, said Cmdr. Marie Casey, USPHS, CMS deputy director of recovery audit operations. And by 2010, in addition to these audits, the RACs will also review the medical necessity of certain claims. Such reviews will rely on the expert medical opinion of physicians and other medical professionals who work for the RACs. Cmdr. Casey added that the RACs can audit any Medicare fee-for-service claims up to 3 years from the payment date, but during the program's early phase will review only claims made on or after Oct. 1, 2007.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that you can avoid making the same mistakes. This information is available at www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
▸ “Make sure that you're in compliance with all the applicable Medicare policies, coverage determinations, coding directives, requirements for documentation,” Lt. Lew advised.
▸ Identify key RAC contacts. (See box.) Each region has its own RAC (www.cms.hhs.gov/RAC/Downloads/Four%20RAC%20Jurisdictions.pdf
▸ Develop processes for tracking and responding to RAC requests and demand letters. “There are timelines attached to demand letters,” Lt. Lew said. “Have a system for tracking those timelines.”
▸ Appeal when necessary. “If you make a business decision that an appeal is warranted, we would certainly encourage you to appeal,” Lt. Lew said.
For more information about the RAC program, visit www.cms.hhs.gov/RAC
Get Ready for the RAC in Your Region
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before an RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic “black and white” reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Starting as early as September, the RACs may begin reviewing coding issues and diagnosis-related group validations, which will require the review of additional documentation.
Once the RAC has been established in the region, the RAC may begin to review claims for medical necessity.
To contact the RAC for your region:
▸ Region A: Diversified Collection Services (DCS), 866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
WASHINGTON — Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country later this summer, with demand letters reaching providers in August or early September, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006 by the Tax Relief and Healthcare Act. It is administered by private contractors who collect a fee based on the errors they detect.
The RACs—which have access to Medicare fee-for-service claims data—use software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated “complex reviews” on diagnosis-related group (DRG) coding errors, said Cmdr. Marie Casey, USPHS, CMS deputy director of recovery audit operations. And by 2010, in addition to these audits, the RACs will also review the medical necessity of certain claims. Such reviews will rely on the expert medical opinion of physicians and other medical professionals who work for the RACs. Cmdr. Casey added that the RACs can audit any Medicare fee-for-service claims up to 3 years from the payment date, but during the program's early phase will review only claims made on or after Oct. 1, 2007.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that you can avoid making the same mistakes. This information is available at www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
▸ “Make sure that you're in compliance with all the applicable Medicare policies, coverage determinations, coding directives, requirements for documentation,” Lt. Lew advised.
▸ Identify key RAC contacts. (See box.) Each region has its own RAC (www.cms.hhs.gov/RAC/Downloads/Four%20RAC%20Jurisdictions.pdf
▸ Develop processes for tracking and responding to RAC requests and demand letters. “There are timelines attached to demand letters,” Lt. Lew said. “Have a system for tracking those timelines.”
▸ Appeal when necessary. “If you make a business decision that an appeal is warranted, we would certainly encourage you to appeal,” Lt. Lew said.
For more information about the RAC program, visit www.cms.hhs.gov/RAC
Get Ready for the RAC in Your Region
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before an RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic “black and white” reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Starting as early as September, the RACs may begin reviewing coding issues and diagnosis-related group validations, which will require the review of additional documentation.
Once the RAC has been established in the region, the RAC may begin to review claims for medical necessity.
To contact the RAC for your region:
▸ Region A: Diversified Collection Services (DCS), 866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
WASHINGTON — Physicians and other providers in certain states are beginning to receive demand letters from Medicare Recovery Audit Contractors, Dr. Thomas Valuck said at a meeting of the Practicing Physicians Advisory Council.
Officials from the Centers for Medicare and Medicaid Services will begin to roll out the program to the rest of the country later this summer, with demand letters reaching providers in August or early September, according to Dr. Valuck, medical officer and senior adviser at the Center for Medicare Management.
The Recovery Audit Contractor (RAC) program is designed to identify and correct past improper Medicare payments, including underpayments. It began as a demonstration project in California, Florida, and New York in 2005, and was made permanent and nationwide in 2006 by the Tax Relief and Healthcare Act. It is administered by private contractors who collect a fee based on the errors they detect.
The RACs—which have access to Medicare fee-for-service claims data—use software to analyze claims for inaccuracies regarding coding, billing, and payment. Beginning in September, the RACs will also conduct computer-facilitated “complex reviews” on diagnosis-related group (DRG) coding errors, said Cmdr. Marie Casey, USPHS, CMS deputy director of recovery audit operations. And by 2010, in addition to these audits, the RACs will also review the medical necessity of certain claims. Such reviews will rely on the expert medical opinion of physicians and other medical professionals who work for the RACs. Cmdr. Casey added that the RACs can audit any Medicare fee-for-service claims up to 3 years from the payment date, but during the program's early phase will review only claims made on or after Oct. 1, 2007.
Cmdr. Casey and her colleague Lt. Terrance Lew, USPHS, a health insurance specialist at the division of recovery audit operations at the CMS, offered the following advice for preparing for an RAC review:
▸ Know where previous improper payments have been found so that you can avoid making the same mistakes. This information is available at www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
▸ “Make sure that you're in compliance with all the applicable Medicare policies, coverage determinations, coding directives, requirements for documentation,” Lt. Lew advised.
▸ Identify key RAC contacts. (See box.) Each region has its own RAC (www.cms.hhs.gov/RAC/Downloads/Four%20RAC%20Jurisdictions.pdf
▸ Develop processes for tracking and responding to RAC requests and demand letters. “There are timelines attached to demand letters,” Lt. Lew said. “Have a system for tracking those timelines.”
▸ Appeal when necessary. “If you make a business decision that an appeal is warranted, we would certainly encourage you to appeal,” Lt. Lew said.
For more information about the RAC program, visit www.cms.hhs.gov/RAC
Get Ready for the RAC in Your Region
Outreach designed to educate providers about the RAC program and what to expect is still being conducted in Regions B and D, and the CMS soon will begin outreach in Region A. The updated provider outreach schedule can be found at
Provider outreach must occur in each state before an RAC is authorized to send any correspondence to a provider, such as a demand letter for recoupment or a request for additional documentation.
The RACs will begin with very basic “black and white” reviews, Cmdr. Casey said, adding that these reviews will be performed on an automated basis (no medical records are required).
Starting as early as September, the RACs may begin reviewing coding issues and diagnosis-related group validations, which will require the review of additional documentation.
Once the RAC has been established in the region, the RAC may begin to review claims for medical necessity.
To contact the RAC for your region:
▸ Region A: Diversified Collection Services (DCS), 866-201-0580;
▸ Region B: CGI, 1-877-316-7222;
▸ Region C: Connolly Consulting Inc., 866-360-2507;
www.connollyhealthcare.com/RAC
▸ Region D: HealthDataInsights Inc., 866-590-5598 (Part A); 866-376-2319 (Part B);
$43 Billion in Unpaid Bills Means Premium Hike for Insured
WASHINGTON The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
"That is the hidden health tax," said the group's executive director, Ron Pollack. "Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is."
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, $116 billion of care from hospitals, doctors and other health care professionals was provided to the uninsured last year. Of this, 37% was paid for out-of-pocket by the patients themselves.
A further 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder$42.7 billionwas unpaid.
"Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance," according to the report. "This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure."
At a press conference to release the report, Ron Williams, the chairman and chief executive officer of Aetna Inc., said that the report answers a question many consumers have, "which is, 'Why does my premium go up?'"
He added, "For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net."
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance committee and a leader on health care reform, said that, "As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year. We must repeal this hidden tax and lift the burden from American families and businesses by ensuring quality, affordable health care for all Americans."
WASHINGTON The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
"That is the hidden health tax," said the group's executive director, Ron Pollack. "Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is."
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, $116 billion of care from hospitals, doctors and other health care professionals was provided to the uninsured last year. Of this, 37% was paid for out-of-pocket by the patients themselves.
A further 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder$42.7 billionwas unpaid.
"Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance," according to the report. "This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure."
At a press conference to release the report, Ron Williams, the chairman and chief executive officer of Aetna Inc., said that the report answers a question many consumers have, "which is, 'Why does my premium go up?'"
He added, "For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net."
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance committee and a leader on health care reform, said that, "As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year. We must repeal this hidden tax and lift the burden from American families and businesses by ensuring quality, affordable health care for all Americans."
WASHINGTON The average U.S. family spent an extra $1,017 on health care last year to help cover uncompensated care provided to the uninsured, according to a report from Families USA.
Privately insured individuals spent an extra $368 last year for the same thing.
"That is the hidden health tax," said the group's executive director, Ron Pollack. "Everybody in the country probably knows that there is such a hidden health tax, but they don't know how significant it is."
According to the report, created with the help of Milliman Inc., an independent actuarial consulting firm, $116 billion of care from hospitals, doctors and other health care professionals was provided to the uninsured last year. Of this, 37% was paid for out-of-pocket by the patients themselves.
A further 26% of this was paid for by third-party sources, such as charities or community centers.
The remainder$42.7 billionwas unpaid.
"Providers attempt to recover these uncompensated care dollars primarily by increasing charges for those with private insurance," according to the report. "This cost shift is borne almost exclusively by private insurance programs because the federal Medicare program's rules do not allow Medicare provider payments to easily adjust upward in response to this pressure."
At a press conference to release the report, Ron Williams, the chairman and chief executive officer of Aetna Inc., said that the report answers a question many consumers have, "which is, 'Why does my premium go up?'"
He added, "For every person who has private health insurance, there is a tax … that these community hospitals and other hospitals have to collect in order to be there as a safety net."
Mr. Pollack stressed that the data in this report are from 2008, and that the huge amount of job loss still occurring in 2009 likely will mean that the amount borne by each U.S. family will grow to $1,100 this year. A similar study conducted in 2005 found that the average family paid an extra $922 to cover uncompensated care and the average individual paid an extra $341.
In a statement accompanying the release of the report, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance committee and a leader on health care reform, said that, "As this report shows, that hidden tax will only continue to grow unless we do something about it. That's why I'm committed to passing comprehensive health care reform this year. We must repeal this hidden tax and lift the burden from American families and businesses by ensuring quality, affordable health care for all Americans."