BLOGS: Womble Commercial Real Estate

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Monday, February 25, 2013, 2:58 PM

Dealing with RAC Audits and Denials: How Healthcare Providers Can Manage Medicare Recovery Efforts

Executive Summary: Medicare RAC (Recovery Audit Contractor) audits are becoming increasingly aggressive, creating delays in payment for healthcare providers. Certain strategies can help mitigate delays caused by RAC audits and denials.

Medicare Recovery Audit Contractors ("RACs") are charged with identifying, on a retrospective basis, overpayments made by Medicare to healthcare providers. Because a substantial percentage of all Medicare payments are made to hospitals, they are often the targets of RAC audits. Increasingly, overpayment determinations made by RACs involve issues relating to the medical necessity of inpatient services previously provided by hospitals, as ordered by attending physicians.

"Medical necessity" is often a far more complex matter than auditors recognize, and providers must often expend considerable time and effort to ensure that RACs do not inappropriately recover funds from them. Providers who have in good faith provided needed care to patients should consider appealing adverse determinations. This is particularly important in reviewing denials, as RACs may issue denials for inpatient admission status, not the medical necessity (and therefore Medicare coverage) of services. Administrative Law Judges ("ALJs") have concluded that in cases where inpatient admissions may not have been documented, the hospital providers should be reimbursed under Part B for all services, including procedures and observation care. In response to these ALJ decisions, in July 2012, CMS issued a directive to contractors to permit rebilling so that providers could be reimbursed for procedures, services and care under Part B, not merely for ancillary services.

Recently ALJs have remanded cases back to contractors involved at lower levels of the appeals process (i.e., to a Qualified Independent Contractor ("QIC") or to the Medicare Administrative Contractor ("MAC"). In their remand orders, ALJs direct that the QIC or MAC calculate an appropriate Part B payment to hospitals for needed outpatient treatments. Importantly, these remands occur before an ALJ has convened a hearing in the appeal and must be decided before a hearing can be set.


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Friday, February 8, 2013, 3:24 PM

BOMA’s 2013 MOB Conference

This will be the fourth year in a row that Phil (one of the other contributors to this blog) and I have attended this conference.  It’s a great conference for all of us healthcare real estate people.  Here’s a good, brief summary of this conference, from BOMA:
“Join more than 700 healthcare real estate executives, CFOs, developers, investors, lenders, facility managers, advisors and architects as they come together to discuss current issues and trends in developing, leasing and managing medical office buildings and other ambulatory care facilities. This comprehensive two-day conference focuses exclusively on healthcare real estate and includes case studies, roundtables, panel discussions, interactive sessions and keynote addresses focused on issues and trends in healthcare and their impact on healthcare real estate.”
I consider it the year's can't miss” healthcare real estate event.
BOMA’s 2013 MOB Conference is May 1-3, 2013, in San Francisco, CA. 

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Tuesday, February 5, 2013, 5:00 PM

Better Late than Never - The Sunshine Act Final Regulations are Finally Here!

Another Womble Carlyle Client Alert....

Late afternoon on Friday February 1, 2013, the Centers for Medicare and Medicaid Services ("CMS") published the final rule regarding Transparency Reports and Reporting of Physician Ownership or Investment Interests ("Final Rule"). The Final Rule will be published in the Federal Register on February 8, 2013, effective 60 days later (April 9, 2013). The Final Rule has been long-delayed, since CMS published the proposed rule on December 19, 2011 (76 FR 78742) ("Proposed Rule"). This alert is intended to highlight a few of the Final Rule's key provisions.

Applicable manufacturers must begin collection of required data on August 1, 2013, and make their first report of data to CMS by March 31, 2014. CMS will then release the data on a public website by September 30, 2014.

Applicable Manufacturers Must Report All Payments or Transfers of Value to Covered Recipients. In the Final Rule, CMS finalizes its proposal to require reporting of all payments or transfers of value to covered recipients, rather than only payments related to covered drugs, devices, biologicals, and medical supplies.

Click each subheading below for a detailed summary of some of the key provisions of the Final Rule:

Other ProvisionsThe Final Rule includes significant discussion regarding each of the form and nature of payment categories, as well as each exclusion type. In addition, the Final Rule includes detailed information regarding research, delayed publication under certain circumstances, report content, report review and correction, the public website, and penalties for failure to report.

If you have questions regarding this Final Rule, please contact Sarah Crotts, the author of this alert. You may also contact the Womble Carlyle attorney with whom you usually work, or any of our Healthcare Industry Team attorneys.

For a printer friendly link to this alert, please click here.

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