Archive for May 2011

It’s time to read up on the RAC

Okay, if you haven’t started getting serious about educating yourself about the Recovery Audit Contractor program, it’s about time you should.

RACs are third parties hired by the Centers for Medicare and Medicaid Services to ensure that physicians are being paid correctly for Medicare Part A and B services. They identify all “improper payments,” whether the physician received too much or too little, and in return receive a share of the booty—I mean, spoils—I mean, identified payments. [Don’t mind me, it’s Friday.]

CMS released an update in late April that showed that in its first 18 months, the permanent RAC program had identified a total of $365.8 million in total improper payments—$312.2 million in overpayments and $52.6 million in underpayments. The agency attributed the four big reasons for improper payments to incorrect coding and billing for bundled services.

The three-year demonstration was wildly successful, too, with more than $900 million in overpayments collected from physicians and suppliers from six states (California, Florida, New York, Massachusetts, South Carolina, and Arizona) and less than $38 million in underpayments repaid.

RACs came to Texas in March 2009 and Connolly Healthcare won the contract for our region, Region C.

Bradley Reiner, TAFP’s practice management consultant, recommends that physicians be involved in the billing process, and implement a compliance plan so employees are aware of potential errors and how to fix them before they become big problems.

The compliance plan is detailed in the second part of an article Bradley wrote for Texas Family Physician in fall 2010. “Ready or not, Recovery Audit Contractors are coming” explains how the program works, how to minimize the risk of being audited, and what to do if you are. Bradley wrote another article in the winter 2009 issue, “Are you ready for the RAC?,” that details the demonstration project.

Both of these will help get you thinking about the RACs so you’ll be prepared if they knock on your door (rather, send a letter). TAFP members can also contact Bradley by phone at (512) 858-1570, or by e-mail at breiner@austin.rr.com for a consultation and discounted services.

The take-away message is that you can’t ignore them. As Bradley says, “If they continue to be successful there is no doubt everyone will have a RAC audit sooner or later. In almost every practice a RAC can find some billing, coding, or documentation issue during any given audit … . The rules are too complex and differ from payer to payer.”

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How a bill really becomes a law: A primer on the legislative process

As time winds down on the 82nd Texas Legislature, lawmakers are working extra-long hours trying to push their bills through the legislative process before a series of deadlines—intended to stretch out a few extremely stressful days to a few fairly stressful weeks—prevents the bills from becoming law. When a bill doesn’t make it to its next stage, it is considered dead, and the past two days marked two very important deadlines in the House. If your bill didn’t make it to second reading on Thursday, May 12, or to second and third reading on Friday, May 13, your bill has been killed and there is very little you can do about it.

Backing up a bit, the whole process seems designed to kill more bills than pass them. Depending on your generation, you either learned the step-by-step legislative process from your high school government class or the School House Rocks tune “I’m Just a Bill.” Away from the textbooks and animation, the real-life convolution of political forces, interest groups, and desire for re-election (of both the candidates and their supporters) means that things often run a bit differently in the Texas Legislature, and understanding how it actually works takes years of observation under the Capitol dome or a little insider’s knowledge.

Here’s the process how it stands on paper:

However, when those conflicting forces and the legislative deadlines get involved, each stage is a potential bill-killer and suddenly getting a bill passed seems impossible. For the purpose of this very simplified illustration, I’ll take fictional and non-controversial House Bill 8000 through the stages.

Stage 1 – Filed

From the time before the even session starts to 60 days in, lawmakers, legislative staff, and interest groups form legislative priorities and craft legislation. Most bills are filed with the full intention of pushing them through to law; some are filed in the full knowledge that they won’t pass, but serve the purpose to lay the foundation for future sessions or appease certain voting groups. After our fictional H.B. 8000 is filed in the House, it is assigned to a committee by the Speaker.

Stage 2 – Out of House Committee

Once a bill reaches committee, the committee chairperson wields much power on its survival. (Note that chairmanship is granted by the Speaker in the House and the lieutenant governor in the Senate.) The chair determines when the bill will be heard—day and time—or if it will be heard at all. Many times a bill will be laid out before the committee, tabled, and never called up again, sometimes because of a backroom agreement to kill a “bad bill.” The best case for H.B. 8000 is that it is laid out before committee members, advocates give moving testimony, and the bill is voted favorably out of committee. Congratulations—our bill just passed a step that a very large number of bills fail.

Stage 3 – Voted on by House

From here, H.B. 8000 must be scheduled by the Committee on Calendars to be heard on the House floor. There are four calendars and each lists bills and resolutions that are scheduled to be considered by the full House. The two most important for law-passing purposes are the Daily House Calendar (that lists new bills) and the Supplemental House Calendar (that lists bills from the Daily calendar, bills passed to third reading the previous day, bills or postponed business from the previous day, and bills that were tabled the previous day). Bills listed on the Local and Consent Calendar are local or noncontroversial bills that are typically passed very quickly without much, if any, debate.

Anyway, all of this is to say that calendar placement is very important, particularly toward the end of the session as each deadline kills scores of bills by the stroke of midnight. There are a bunch of deadlines coming up, in addition to the two mentioned above. Here’s a link to the full calendar of deadlines. Essentially, your bill has to be heard on the House floor and pass in time to go through the whole Senate process, all before sine die.

So, back to H.B. 8000, which was placed on the Local and Consent Calendar and, in a bipartisan show of goodwill, passed unanimously out of the House (hooray).

Stage 4 – Out of Senate Committee

Because our bill does not already have a companion bill in the Senate, which would shorten the process considerably, H.B. 8000 is assigned to a Senate committee by the lieutenant governor where it goes through the same committee hearings as it did in the House. This is a new ballgame with different legislators who may have different priorities. As a result, even more bills die here. Thankfully, H.B. 8000 is passed and goes onto the next stage.

Stage 5 – Voted on by Senate

The bill now goes to the Senate. With some prep work beforehand, it is placed on the Intent Calendar and brought before the full Senate by a vote of two-thirds of the senators present. Sheer paperwork kills bills here. If the Senate doesn’t bring up a bill on the day it is listed on the Intent Calendar, a senator must take action to list it on the following day’s calendar. The pesky deadlines also get in the way: If a bill is brought up for second reading, but not the third, it cannot pass. In our case, H.B. 8000 passes without amendments and goes on to the next step.

Stage 6 – Sent to Governor

Once the bill passes the Senate and has been sent back to the House, the bill is prepared for signing, signed by the Speaker and the lieutenant governor, and sent to the governor who must sign the bill, veto it, or allow it to become law without signature. The last day the governor can take action on a bill passed during the 82nd regular session is Sunday, June 19. If vetoed after sine die, the bill is dead. Our bill, however, is signed and moves on to the next and final stage.

Stage 7 – Bill Becomes Law

H.B. 8000 becomes law. Woo!

And there you go. Even in a simplified state, it still seems complicated. That’s why, once again, I’m amazed any bills are able to be passed. Because legislators are dealing with such large, polarizing issues (i.e. a tough budget and redistricting, among others), experts predict they’ll be called back in the summer for a Special Session when we’ll start all over again.

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