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December 9, 2011


SCAI Responds to CMS National and Local Plans for Prepayment Audit of Claims

SCAI is very concerned about plans by CMS and its contractors to engage in prepayment review of charts for appropriateness through the Recovery Audit Program Prepayment Review demonstration and carrier-specific programs. In Florida, the Medicare Administrator Contractor (MAC) Firstcoast will be focusing on prepayment review of 15 DRGs, including stent implantations, PCI procedures without stents, other vascular and circulatory-system procedures, as well as ICDs, pacemakers, and a few noncardiovascular procedures.

FirstCoast reports it will begin chart review starting Jan. 1 and could reach 100 percent chart review. Details on what type of claims will be audited by the national Recovery Audit Program Prepayment Review demonstration --  targeting Florida and 10 other states   reportedly including California, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas -- have not been provided by CMS. This program is also slated to begin Jan 1.

Seeking clarification and transparency, SCAI has been in contact with the Acting CMS Administrator, who responded there “has been some confusion on this issue” with subsequent redirection to other CMS staff. Meanwhile, SCAI has learned more about the plan for chart review in Florida and has spoken on the issue with theheart.org journalist Shelley Wood.

Details on the Plan for Florida

FirstCoast held a webinar yesterday, where it revealed more details about its Florida prepayment audit program; however, many questions remain unanswered, including critical information on criteria to be applied in FirstCoast’s determinations on appropriateness and medical necessity for the procedures themselves as well as for admission status.

FirstCoast did confirm plans to conduct prepayment review of the 15 DRGs cited above and goals that could reach 100 percent of these inpatient claims. However, while FirstCoast officials cited a history of high claims processing error rates as the impetus for inclusion for some of the targeted services on FirstCoast’s “hit list,” they provided no detail regarding the basis for the inclusion of the coronary stent DRGs as targeted procedures.

FirstCoast affirmed it will review charts focusing on two areas – (1) appropriateness and medical necessity for the procedure itself and (2) appropriateness of hospital admission. FirstCoast’s auditors asserted they hold physicians accountable for both determination of admission status and ensuring hospital records support this determination. Therefore, related physician claims will be subject to post-payment audit for claims for which inpatient status is denied. FirstCoast was noncommittal on what the practical outcome from post-payment audit of these physician claims would be. At one point, spokespersons stated the claims would be auto-corrected regarding the site of service (i.e., conversion from inpatient to outpatient). But later in the program they stated physicians should expect to receive letters seeking retraction of the payment of these services. 

Media Coverage

Responding to media queries, SCAI President Christopher W. White, M.D., FSCAI, has spoken about SCAI’s concerns about the CMS plans for auditing, its implications for patient care, and the tools SCAI has provided interventionalists to assist in them in the ongoing effort to deliver guidelines-driven care.  Speaking with Ms. Wood from theheart.org, he highlighted SCAI’s Quality Improvement Toolkit and ACE accreditation.  Ms. Wood paraphrased Dr. White’s comments on these tools:  “It would make more sense, White said, for the CMS to work with cardiology leaders on appropriateness decisions, rather than reinvent the wheel.”

On CMS’s plans for chart review, theheart.org quoted Dr. White: “There is a key fundamental flaw when government starts to interact with how patients get healthcare ... This needs to be very transparent, because it has the opportunity to adversely impact healthcare. ... When doctors and hospitals are put in risk scenarios, they become risk averse, and sometimes patients get the short end of the stick. ... Everybody understands that doing things to patients that are not necessary is bad, but what people are missing is that not doing the right things for patients who need them is just as bad and perhaps even worse. So putting barriers in place that make it difficult for patients to get what they need is a form of rationing."

As this issue continues to unfold, SCAI’s advocacy team will work with cardiologists in the targeted states and other cardiology organizations. SCAI will continue to press FirstCoast and CMS for more details and will make every effort to mitigate the impact of these prepayment audit programs on members, the hospitals they serve, and the patients they treat. To learn more about these plans and SCAI’s actions in response, stay tuned to www.SCAI.org.

Read theheart.org Story