Coping with Regulatory and Payer Demands to Practice PM&R Bruce M. Gans, MD

 Payers are seeking ways to avoid payment, shift responsibility, and minimize their exposure to all providers, including physicians

 Do the right things clinically  Document them well  Code accurately and completely  Inform the patient of their liability for paying for your services before you provide them  Collect co-pays at the time and site of service when possible  Review your insurance plan participation regularly  Review your collections regularly  Understand your contractual allowance rates

 Audit your records yourself for documentation and coding accuracy  Cross-audit your charts with other providers  Engage external auditors to review, critique, and educate yourself and your staff

 Appeal everything  Follow the rules meticulously  Engage professional help  Track your success  Learn from your mistakes or failures to win

 Medical Administrative Roles  Employment  Independent Contractor  On-call arrangements  Risks to be avoided  Review the contract carefully  Document your work if you must invoice for payment  Do the work you invoice for  Make sure your payment rate is truly fair market value

 Clinical Roles  Incorporating Medicare documentation requirements for inpatient rehab care into your practice  Separating or commingling administrative and clinical services  Gym rounds  Team meetings with patients  Use of extenders

 Patients come first  Balance your obligation to your patient with the responsibility to show reasonable restraint in how you provide care and authorize/prescribe drugs, goods and services  Work in close alignment with others involved in the care of your patients  You are looked to as a leader, so lead with wisdom, grace and integrity

Peter W. Thomas

 Existing RACs continue to audit certain claims  RAC legal challenge delays awards of new round of RACs  Changes to RAC contracts that benefit providers

 Additional Documentation Request limits by provider group

 New authority for CMS contractors to deny related claims  Specific rules governing denial of related claims

 Extent of ALJ hearing backlog  AHA Lawsuit to challenge ALJ delay  FAIR Fund Amicus brief to demonstrate harm to providers  68% Settlement offer for acute care hospitals re: short day stays  Impact of developments on appeals process  Pointers on challenging denials of claims, including recoupment and interest

 Series of Congressional hearings exposing burden on providers  GAO Report on Medicare Audit Contractors  Senate Special Committee on Aging Report on Audits and Appeals  Pending legislative efforts on Medicare audits and appeals

 Status of Physician documentation “template” being developed by CMS  Prior Authorization of certain DMEPOS  Regulatory changes involving Off-the-Shelf Orthotics

 Round II and the future of Medicare competitive acquisition of DME  National pricing based on competitive bidding  Impact of coding on access to DMEPOS care