The Medicare audit and appeals process: a guide for interventional pain practitioners.
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BACKGROUND: Health care is a highly regulated industry and interventional pain physicians (IPPs) are right in the government's bull's eye. Over the next few years, IPPs will find themselves responding to audit requests from Medicare. An IPP's response to a Medicare record request should be tailored specifically to the type of request and the specific circumstances of the IPP. With so much at stake, IPPs should not underestimate the importance of an immediate and thoughtful response. OBJECTIVES: This article discusses 1) the various types of record requests used by Medicare, 2) the practical steps an IPP should take in response to a record request, 3) the Medicare appeals process, and, 4) the practical steps an IPP should take in connection with the appeals process. DISCUSSION: IPPs should maintain an effective compliance program and ensure that medical records are appropriately documented before any audit takes place. If a Medicare audit decision is unfavorable, IPPs should understand the available appeals process and the steps that need to be taken to win the appeal. CONCLUSION: With advance preparation and a considered response, IPPs can positively influence the outcome of a Medicare audit. (+info)
Physician payment reform--an idea whose time has come.
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These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Homer A. Boushey, MD, Professor of Medicine, and Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith, Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143. (+info)
A rational process for the reform of the physician payment system.
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Analysis of the resource-based relative value scale (RBRVS) for physician payment indicates that in 1996, hourly reimbursement rates will be unrelated to the intensity of work and income will be unrelated to hours worked. A "consensus method" of payment is proposed as an alternative to the RBRVS. METHOD: As with the method of the RBRVS study, a pilot survey asked a specialty-representative cohort of physicians to assign dimensionless numbers to the relative value of work in 15 specialties using the Hsiao et al. definition of work intensity as "time modified by, a) mental effort, b) clinical judgment, c) technical skill, and d) physical effort under stress." The consensus method is similar to that of the Hsaio method, except there is no mathematical transformation of the raw data to establish specialty work values once the data are collected. A comparative analysis was then made of work hours, reimbursement rates, and annual income with 1) the customary prevailing and reasonable system (CPR, pre-1992), 2) the RBRVS system (1996), and 3) the proposed consensus system. RESULTS: The RBRVS intends that physicians be reimbursed on the basis of time and intensity of work. Neither the CPR nor the RBRVS systems accomplish this objective when the data and computational methods of the Physician Payment Review Commission are used with independently determined work intensity to compute hourly reimbursement rates in the specialties. The consensus method shows the desired direct linear correlation of income with both length of the physician's work week and intensity of effort. It rates the primary care specialties as a group more highly than the RBRVS. CONCLUSION: The proposed consensus method meets the original intent of the RBRVS to reimburse physicians on the basis of the resource input of time as modified by the criteria of Hsiao et al. (+info)
Physician behavioral response to a Medicare price reduction.
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OBJECTIVE: To investigate at the individual practice level physician behavioral responses to the Medicare fee reductions mandated in the Omnibus Budget Reconciliation Act of 1989. Symmetric and nonsymmetric behavioral responses are modeled and investigated. DATA SOURCES: Volume index calculated from data in the Part B Medicare Annual Data (BMAD) Provider Files for 1989 and 1990. The pricing data are from the Procedure Files. STUDY DESIGN: A fixed-effects model in carrier and in specialty is employed. DATA COLLECTION: No direct data collection is required as BMAD files are used in the study. Price and volume variables are expressed as Fisher indexes of change. PRINCIPAL FINDINGS: The results show nonsymmetrical behavioral response because practices that did not face significant fee reductions do not exhibit behavioral change. By contrast, losers partially compensate for the fee reductions. For every dollar cut in their fees, physicians recoup approximately 40 cents by increasing volume. Loser behavioral responses vary by specialty. CONCLUSIONS: The presence of a volume response suggests that price control alone is not sufficient to cap rising healthcare costs. This indicates that additional or other tools must be considered if cost containment is to be attained. (+info)