"In an effort to reduce insurance fraud, waste and abuse, the Centers for
Medicare and Medicaid Services will require pre-payment reviews for
specified surgeries and pre-reimbursement authorizations for medical
equipment in 11 states starting on Jan. 1, 2012.
In recovery audit prepayment reviews, inspectors will review claims for such
surgeries as spinal fusions, joint replacements and pacemaker or
defibrillator surgeries in order to prevent improperly paid claims before
they're processed. This would provide an alternative to recovering
overpayments after they're made. An appeals process would be set up for the
potential resubmission of denied claims. Recovery audit prepayment reviews
will affect providers in California, Florida, Illinois, Louisiana, Michigan,
Missouri, New York, North Carolina, Ohio, Pennsylvania and Texas."
Recovery Audit Prepayment Review: The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they have been made."
Florida Medicare actual put into place LCDs for these procedures apparently to start this process. You will want to access those also:
First Coast Service Options will implement a new Local Coverage Determination for Major Joint Replacement on October 16, 2011. The LCD will require physicians to enhance documentation of conservative treatment and indications to support the medical necessity of total hip and total joint replacements in the hospital record in addition to the office based patient record.
The basis of this LCD is the Comprehensive Error Rate Testing (CERT) audits that have called into question the medical necessity of some of these procedures when auditing in-patient hospital records. Due to a lack of documentation of conservative therapy and indications for surgery in some instances the audits have resulted in requests for the hospital and physicians to return compensation for those procedures.
The LCD will require physicians to enhance the documentation they provide in the hospital records. FOS members need to adhere to this LCD to protect their reimbursements.
The FOS worked directly with the AAOS, the Hip and Knee Societies, AAHKS, and First Coast Service Options to make significant changes to the initial proposal. We are pleased that FCSO did make many of the changes that we requested. We do need to hear from you if you discover any issues with the LCD once implemented.