rac vs. oncology a coalition-building prototype to quell onerous attacks
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RAC VS. ONCOLOGY A COALITION-BUILDING PROTOTYPE TO QUELL
ONEROUS ATTACKS
Dane J. Dickson MDPresident 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.”
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Know yourself Remember
FDA LabelsGuidelines (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
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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 WorkSept 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 WorkSept 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 Recoveryhttps://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/CMSRacProgram.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
Audit Item
CMS
Proprietary Data
Review
“Low Hanging
Fruit”
RAC
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Notification of Audit Item
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Finding RAC Audit Items Region Ahttps://www.dcsrac.com/IssuesUnderReview.aspx Region Bhttps://racb.cgi.com/Issues.aspx Region Chttp://www.connolly.com/healthcare/pages/ApprovedIssues.aspx Region Dhttps://racinfo.healthdatainsights.com/Public1/NewIssues.aspx
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Simplifying the RAC Process
RAC Request
Provider Rebuttal
Appeal 1 MAC
Appeal 2 QIC
Appeal 3 ALJ
Appeal 4DAB
Appeal 5 US District Court
MAC: Medicare Administrative ContractorQIC: Qualified Independent ContractorALJ: Administrative Law JudgeDAB: 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, and Allies
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Objectives/Strategies
RAC Provider Rebuttal
MAC
CMS
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MAC to CMS to RAC
“Stop Audit”1
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MAC
“Overturn RAC”2
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CMS
“Stop Audit”3
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RAC
“Unreasonable”4
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Escalated Strategies (If Needed)
RAC ProviderMAC
CMS
Share Holders
CongressPatients 5
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Congress
“Bad Policy”5
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6Corporate Leadership
“Very bad PR”6
Performant: PFMT CGI: GIBConnolly: PrivateHDI: 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 CoalitionIdaho Oregon
Utah
Alaska
Montana
Nebraska S. California
Washington
State Societies
COA
CMSMAC
PRIT
ASCOCPC
SAC
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 mobilizationRapid response and focused perspectiveInvolved CMS/PRIT
State AdministratorsLogistic supportCommunication 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, theconcerns 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.”
CMS Position Suffers from lack of funding
and low visibilityWilliam D Rogers MD
Medical Officer CMS and Director Physicians Regulatory Issues Team
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MAC - Noridian Medicare Administrative
Contractor – Jurisdiction F and Minnesota
After receiving information from the State SocietiesContacted CMS – halted audit“We are going to overturn them
all on appeal any way. . .”
“GET INVOLVED!”Bernice Hecker MD
Contract Medical Director Parts A&BNoridian Administrative Services
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Noridian – Coverage Letter“Based on the evidence, the administration of same-daypegfilgrastim has become an accepted standard of care and in particular, in situations where patients are believedto be a higher risk of potential non-compliance with day 2 administration.
“. . .the administration of pegfilgrastim before the traditional 14day window has become an accepted standard of care to maintain dose-density or reduce neutropeniccomplications 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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Why does one RAC Drug Audit Matter?
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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 26States Represented 19
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 70%Medicaid 3%Private Insurers 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 hoursAverage days until resolution of a single review 53 days
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Where do we go from here?
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Using an Unified Oncology Coalition to Drive Policy
State Societies
COA
National (CMS)
ASCOSAC
Statewide (Private Insurers)
Patients and
Advocates
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Possible Areas to Address Pre-authorization
Develop a standardized method of authorization for all insurers
Simplify the process – especially with on-label drug usage
Quality MeasuresDevelop standard methodology of
measuring qualitySimplify the process
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Possible Areas to AddressEstablishing 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:4. 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:5. FDA Label trumps everything else, NCCN Drug Formulary/etc. next,
NCCN/ASCO Guidelines next.6. 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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“If we don’t lead, we will concede.”
Summary
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