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2015 – A Big Year for Audits

As the New Year begins, Recovery Auditors (RACs) have lawsuits preventing them from moving forward and a number of congressional leaders are saying RACs aren’t working in the way intended. RAC denials of payment to hospitals were determined to be very inconsistent in 2014, as most denials were overturned on appeal, and the appeals created a significant traffic jam for the courts. In October 2014, when CMS made a settlement offer to pay just 68% of the value of denied claims that were stuck in the appeals process, most healthcare organizations decided to accept the 68% payment rather than waiting 3-5 years for a determination on their appeals from an Administrative Law Judge (ALJ). Getting some payment now, they decided, was better than the possibility of getting nothing later. Many observers expect that the ability for an ALJ to overturn denied claims on appeal will be markedly diminished in 2015. Some observers are wondering whether every time CMS gets into trouble, they will just make a lump sum settlement offer. Time will tell. One thing seems certain. CMS plans to use a big stick to control physician behavior. In 2015, if hospital charges are denied, then all related physician charges will also be denied payment. Now docs will need to leap to ensure documentation is in place or else they won’t get paid. Accordingly, there is an expected increase in physician audits this year. A new day dawns with OPPS 2015. Get your house and data in order. For more about the 2015 OPPS Final Rule, enjoy the Finally Friday program featuring Craneware’s Bill Malm. What are your New Year’s resolutions to counter the audit onslaught? How will you educate departments and physicians to keep them current with ongoing requirements? Share your thoughts and tips here.