An update to VSNJ membership from the Carrier Advisory Committee representative, Dr. Cliff Sales

The CAC meeting was held this week for Medicare with the new contractor (Highmark Medicare Services.)  They certainly speak the right language and appear to want to be fair in administering the Medicare dollars (they do NOT make judgments about how much to pay, etc.)

Once again, the issue of CERT (Comprehensive Error Rate Testing) was THE main topic of discussion!  Basically, they have data to show that Medicare OVERPAID $9.8 billion in 2006 (the last year that data is available) in claims.  Now, $9.8B seems a drop in the bucket these days when talk is on hundreds of billions--but that is REAL money that CMS feels they can recoup!

Highmark has data on all specialties, all counties, etc etc!  Nationally, the total "error" rate is 5%--Vascular Surgery (nationally) has an error rate of 4.4%!  However, NJ docs (in total) have an error rate in excess of 7% (7.3%) which is the SECOND HIGHEST IN THE NATION!  Not only that,  but it is rising!  Guess what...we are going to be targets!!

They have identified the following as drivers of the error rates:

1. Consultation (especially Inpatient Levels IV and V)

2. Subsequent office visits (esp. 99214)

3. Hospital Visits (99231-3)

4. Hospital Discharges (99238-9)

5. All interpretations (i.e., those with a -26 modifier) MUST have a WRITTEN report

The carrier stressed that IF you are audited (the outside company contracted by CMS is ADVANCE MED and they are based in Virginia):

1. Make certain that you send the COMPLETE chart--everything you have.

2. If it is found that you coded in correctly and you disagree (AND you have documentation to support your argument), make certain you APPEAL it!  The carrier itself will conduct the audit--not Advanced Med!  Even though it might be a pain, it will work well for all of us if you fight it if you think you are right!

**If you are unsure about coding, the carrier has some very good info on their website (www.highmarkmedicareservices.com).  They also have webinars you can attend and they have some live sessions.  IN fact, they are willing to do an E&M session for a group if there is enough interest.

Those were the main take home points!!  Good luck and be careful!