By Stephanie Gallagher, JD
stephanie.gallagher@corporatecompliance.org
Prescription for Change: Congressional Actions Impacting Managed Care Providers
Presenter: Kim Brandt, Chief Healthcare Investigative Counsel for Senate, US Senate Finance Committee
Today’s Managed Care Compliance Conference kicked off with a fantastic discussion of the goings-on on Capitol Hill and how the upcoming presidential election may effect the managed care profession, presented by Kim Brandt, Chief Healthcare Investigative Counsel for Senate, US Finance Committee.
We kicked off the session with a discussion of the political outlook for 2016. Ms. Brant outlined the 2015 Finance Committee progress. In 2015, 38 bills passed out of the Finance Committee, which is the most bills since the 1980’s. Slightly less than half were healthcare related and over one third of those bills have gone on to become law already. Since 2016 is a Presidential Election Year, we are expecting some big changes in the House, Senate, and White House.
We then transitioned into an informative discussion about RACs, what they are, and what some of the issues are surrounding these professes. RACs are paid on a contingency-fee basis. CMS coding standards are complex and constantly changing, and the five-level appeals process. Some of the problems that can arise with the profess include overloaded systems, and other issues. To address this, CMS has updated RACs. There was also a detailed discussion about Medicare Part C RACs. See presentation slides for details.
Ms. Brandt also discussed the Audit & Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015 (AFIRM). ARRIM was passed on June 4, 2015. There are already some proposed changes to AFFIRM.
The proposed changes to AFFIRM seek to:
- Improve oversight capabilities for HHS/CMS that increase the Medicare auditors and claims appeals processes.
- Coordinate efforts between auditors and CMS to ensure that all parties receive transparent data regarding audit practices, improved methodologies, and new incentives/disincentives to improve auditor accuracy.
- Establish voluntary alternate dispute resolution processes to allow for multiple pending claims with similar issues of law or fact to be settled as a unite, rather than as individual appeals.
- Ensure timely and high quality reviews, raise amount in controversy for review by ALJ to match amount for review by District Court.
- Allow for the use of sampling and extrapolation, with the appellant’s consent, to expedite the appeals process.
This first General Session was a great way to get the feel of the current political landscape and upcoming changes that may affect managed care professionals. There were a lot of other great information including the AMP Rule, Risk Adjustments, Network Adequacy, Formulary Management, Co-Ops, and State Exchanges. To view the presentation slides, click here.