Dane J. Dickson MD
President Idaho Society of Clinical Oncology
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Sun Tzu 孫子 – The Art of War
“If you know the enemy
and know yourself, you
need not fear the result
of a hundred battles.”
3
Know yourself
Remember
FDA Labels
Guidelines (NCCN, ASCO, etc.)
Published Literature (not abstracts!!!!)
Standard of Care
Payment for an issue doesn’t necessarily
mean that the payer agrees with your
medical decision
4
RAC Demonstration Program
2003 Medicare Modernization Act
(MMA) – Section 306
3-year demonstration program using
Recovery Audit Contractors (RACs) to
detect and correct improper payments in
the Medicare FFS program
Initially started in states of New York,
Massachusetts, Florida, South Carolina
and California
Ended on March 27, 2008
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Results of the 3 year project
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Results of the 3 year project
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Results of the 3 year project
• Only 14% of
audits
appealed
(with a 33.3% chance
you would win).
• If you are a
RAC you have
a 95% success
rate.
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Results of the 3 Year Project
Lessons Learned:
“Claim RACs are able to find a large
volume of improper payments.”
“Providers do not appeal every
overpayment determination.”
“Overpayments collected were
significantly greater than program costs.”
…
“It is possible to find companies willing to
work on a contingency fee basis.”
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Results of the 3 year Project
“The RAC demonstration had limited
financial impact on most providers. .
.those repayments were small in
comparison with the providers’ overall
income from Medicare.”
“. . .the RAC . . .cost only
20 cents for each dollar
collected”
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Results of the 3 year Project
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Updated Statement of Work
Sept 1, 2011
Added a 3rd audit category
Semi-automated Review
“To be used in [cases where] a clear CMS
policy does not exist but in most instances
the items and services as billed would be
clinically unlikely or not consistent with
evidence-based medical literature.”
Prior to this, only Automated and Complex
Reviews
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Updated Statement of Work
Sept 1, 2011
RACK – Medieval Torture Device
RA – Egyptian Sun Deity
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RAC Regions
Follows the DME Regions for Medicare
Region A: Performant Recovery
https://www.dcsrac.com/Default.aspx
Region B: CGI Federal, Inc.
https://racb.cgi.com/default.aspx
Region C: Connolly, Inc.
http://www.connolly.com/healthcare/Pages/CM
SRacProgram.aspx
Region D: HealthDataInsights, Inc.
http://www.healthdatainsights.com/rac.htm
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CMS – RAC Regions
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Semi-Automated Review
8/30/2012
“This letter is notify you
that the Recovery Auditor
HDI believes that
Medicare has potentially
made an overpayment to
you. . . .Pegfilgrastim
should not be
administered during the
24 hours after
chemotherapy.”
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How RACs Determine Major
Audits
“Low
Hanging
Fruit”
Proprietary
Data
Review
RAC
CMS
Audit Item
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Notification of Audit Item
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Finding RAC Audit Items
Region A
https://www.dcsrac.com/IssuesUnderReview.aspx
Region B
https://racb.cgi.com/Issues.aspx
Region C
http://www.connolly.com/healthcare/pages/ApprovedI
ssues.aspx
Region D
https://racinfo.healthdatainsights.com/Public1/NewIss
ues.aspx
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Simplifying the RAC Process
RAC
Request
Provider
Rebuttal
Appeal 1
MAC
MAC:
QIC:
ALJ:
DAB:
Appeal 2
QIC
Appeal 3
ALJ
Appeal 4
DAB
Appeal 5
US District
Court
Medicare Administrative Contractor
Qualified Independent Contractor
Administrative Law Judge
HHS – Departmental Appeals Board
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Sun Tzu 孫子 – The Art of War
“. . .in war the
victorious . . .only seek
battle after the victory
has been won,
whereas he who is
destined to defeat
fights first and then
looks afterwards for
victory.”
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Objectives/Strategies
3
CMS
MAC to CMS to RAC
1
“Stop Audit”
“Stop Audit”
CMS
1
3
1
MAC
RAC
4
RAC
“Unreasonable”
4
Provider
Rebuttal
1
2
2
MAC
“Overturn RAC”
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Escalated Strategies
(If Needed)
Patients
5
Congress
5
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CMS
Corporate Leadership
“Very bad PR”
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5
Congress
“Bad Policy”
5
MAC
Share
Holders
Performant:
CGI:
Connolly:
HDI:
Provider
RAC
PFMT
GIB
Private
HMSY
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Business of RAC
HDI Acquired by HMS
Holdings
11/7/2011 Announced
3 month increase of
25% vs. 10% for Dow
Approx. increase in
market value
$670 Million
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“Why bring a nuclear missile to a
knife fight?”
Inherent conflict of interest of the RAC
Defining “not consistent with medical literature”
Personal Experience/Concerns with RAC
Loss of Records
○ Inability of RAC to find records
Faxed
Certified mail
○ Response not received = automatic denial, and no
further work needed to be done by RAC (MAC now
does the work)
Over 3 year look back on audit item
○ Surprising given complete access to billing and
payment records
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Unified Oncology Coalition
Idaho
Oregon
Utah
Montana
Washington
Alaska
Nebraska
S. California
COA
SAC
ASCO
CPC
State Societies
MAC
PRIT
CMS
RAC
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States/State Societies
Alaska - Denali Oncology Group
Southern California (MOASC)
Idaho Society of Clinical Oncology (ISCO)
Montana – Frontier Cancer
Nebraska Oncology Society (NOS)
Oregon Society of Medical Oncology
(OSMO)
Society of Utah Medical Oncologists
(SUMO)
Washington State Medical Oncology
Society (WSMOS)
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COA/Administrators
COA
Amazing communication and mobilization
Rapid response and focused perspective
Involved CMS/PRIT
State Administrators
Logistic support
Communication and direction
THANK YOU!
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American Society of Clinical
Oncology
Although physicians clearly do not like
to receive letters from the RACs, the
concerns described below are well
beyond such general frustrations and
involve very specific, significant flaws
with this particular audit. Any one of
these concerns warrant suspension of
the audit. Especially given the
implications when these issues are
taken in combination, we urge CMS to
intervene and suspend the ongoing
RAC audit in Region D and to ensure
that the same audit is not pursued in
other regions of the United States.
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CMS - PRIT
Physicians Regulatory Issues
Team
Small group since 1999
“. . . working hard to identify issues,
chase them down, and create
solutions that are truly tangible to
the practicing physician.”
William D Rogers MD
Medical Officer CMS and Director
Physicians Regulatory Issues Team
CMS Position
Suffers from lack of funding
and low visibility
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MAC - Noridian
Medicare Administrative
Contractor – Jurisdiction F
and Minnesota
After receiving information
from the State Societies
Contacted CMS – halted audit
“We are going to overturn them
all on appeal any way. . .”
Bernice Hecker MD
Contract Medical Director Parts A&B
Noridian Administrative Services
“GET INVOLVED!”
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Noridian – Coverage Letter
“Based on the evidence, the
administration of same-day
pegfilgrastim has become an accepted
standard of care and in particular, in
situations where patients are believed
to be a higher risk of potential noncompliance with day 2 administration.
“. . .the administration of pegfilgrastim
before the traditional 14
day window has become an accepted
standard of care to maintain dosedensity or reduce neutropenic
complications in regimens with
substantial myelosuppression.”
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? Final Results of Audits
RAC contacted our practice saying that
our appeal was accepted and no
overpayment existed
This included the audit that they lost
Most practices had all same day
pegfilgrastim audits overturned but . . .
Nebraska fights on – ? If RAC reviewed,
? If MAC reviewed, ? next steps
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COA/ISCO National Post-Payment
Review Survey (1 of 3)
Informal, non-scientific survey written by ISCO and sent by COA
(thank you Mary Jo Wichers and Bo Gamble) to practice
administrators nation wide. Completely voluntary with no follow up.
# of respondents
States Represented
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How Frequent are Post Payment Reviews in the Following Areas:
Chemotherapy
62%
WBC
31%
RBC
15%
Anti-emetics
15%
(Note: each area independent – some practices have received
audits in multiple areas)
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COA/ISCO National Post-Payment
Review Survey (2 of 3)
Who is conducting the audits?
Medicare
Medicaid
Private Insurers
70%
3%
27%
How often has the audit been performed even when a pre-authorization
was obtained: 34%
How often was the following successful in retaining payment:
Provide Records
64%
Showing guidelines or compendia 27%
Providing clinical trial information 17%
Talking to Medical Director
6%
Legal Action
1%
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COA/ISCO National Post-Payment
Review Survey (3 of 3)
When a claim had to be repaid, how often was the following
the reason for the repayment:
Lack of unbiased review by payer
35%
Mistake by Billing or Coding
28%
Other
19%
Use of therapy outside of guidelines or compendia
14%
Limited research
5%
Number of man hours spent on post payment
review/month
20 hours
Average days until resolution of a single
review
53 days
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Using an Unified Oncology
Coalition to Drive Policy
Patients
and
Advocates
COA
State
Societies
SAC
ASCO
National (CMS)
Statewide (Private Insurers)
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Possible Areas to Address
Pre-authorization
Develop a standardized method of
authorization for all insurers
Simplify the process – especially with onlabel drug usage
Quality Measures
Develop standard methodology of
measuring quality
Simplify the process
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Possible Areas to Address
Establishing National Rules for Drug Audits
Private Insurers:
1.
If pre-authorization was given – then this claim shall never be subject
to post-payment review.
2.
If pre-authorization becomes even more arduous, then there shall be
an expectation that payers will reimburse this administrative burden.
3.
Any disputed claim should be subjected to an independent review
board.
Medicare:
1.
Any RAC audit item that deals with a “standard of care” issue – should
be reviewed and agreed upon by an independent society before CMS
approves it.
Both:
When dealing with the appropriate use of drug:
1.
FDA Label trumps everything else, NCCN Drug Formulary/etc. next,
NCCN/ASCO Guidelines next.
2.
Sequencing of drug shall not be a look-back audit item. If a payer
wants to look at sequencing (i.e. pathway) it should be established
and communicated up front.
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Summary
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