Austin Medical Times

Are You Prepared for a Medicare Recovery Audit Contractor (RAC) Audit?

Themission of the CMS Medicare Fee for Service (FFS) Recovery Audit Program is to identify and correct improper payments made on claims for healthcare services provided to Medicare beneficiaries. In January 2010, the Social Security Act authorized the Recovery Audit Program expansion nationwide and extended it to Medicare Parts C and D.

Any medical practice submitting claims to a government program can be subject to a Medicare Recovery Audit Contractor (RAC) audit. RAC audits—which may be triggered by an innocent documentation error— are not one-time or intermittent reviews. They are part of a systematic and concurrent operating process created to ensure compliance with Medicare’s clinical payment criteria and documentation and billing requirements. The RACs are charged with finding “improper payments”— which could be either an underpayment or an overpayment.

The RACs use proprietary software programs to identify potential payment errors in areas such as duplicate payments, fiscal intermediaries’ mistakes, medical necessity, and coding. RACs also conduct medical record reviews and are required to employ a staff consisting of nurses, therapists, certified coders, and a physician medical director.

According to the CMS report on Improper Payment Rates and Additional Data, between 2012 and 2022, RAC identified improper payments under the Medicare Fee-for-Service program ranging from a high of 12.7 percent in 2014 to a

low of 6.26 percent in 2021. Improper payments may include fraud or abuse. Most improper payments are from unintentional errors or insufficient payment documentation.

The RACs detect and correct past improper payments so that CMS can implement actions to prevent future improper payments. CMS anticipates the following benefits:

• Providers can avoid submitting claims that do not comply with Medicare rules.

• CMS can lower its payment error rate.

• Taxpayers and future Medicare beneficiaries are protected.

Who Is Subject to a RAC Audit?

The following entities are subject to RAC audits:

• Hospitals.

• Physician practices.

• Nursing homes.

• Home health agencies.

• Durable medical equipment suppliers.

• Any provider or supplier that submits claims to Medicare or a government program.

Who Is the RAC Auditor?

CMS contracted with RAC auditors for five regions in the United States and designated one for each

region. It is important to identify the RAC auditor in your region so you can promptly address correspondence from them. CMS has awarded FFS RAC contracts to the following organizations:

Region 1: Performant Recovery, Inc.

Region 2: Performant Recovery, Inc.

Region 3: Cotiviti, LLC

Region 4: Cotiviti GOV Services

Region 5: Performant Recovery, Inc.

The RAC auditor for Region 5 has a national contract to perform audits of durable medical equipment, prosthetics, orthotics, and supplies claims, as well as home health and hospice claims.

CMS provides Medicare FFS RAC contact information and a map outlining the regional division of states. What Does the RAC Review?

The RAC, which reviews claims on a post-payment basis paid within the past three years, conducts three types of reviews:

• Automated—no medical record needed.

• Semi-automated—claims review using data and potential human review of a medical record or other

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Legal Matters

CMS Proposes $9B Lump Sum Payment in Relief For 340B Hospitals

remedy amount between CY 2018 –September 27, 2022 was $10.5B among 1,649 CEs.

Covered Entities (CEs) are getting a glimpse into what they can expect to be repaid due the fallout from CMS’ unlawful 340B payment reduction that was struck down by the U.S. Supreme Court in June 2022. CMS discussed a potential budget neutral lump sum payment process in its highly anticipated Hospital Outpatient Prospective Payment (OPPS) Remedy for the 340B-Acquired Drug Payment Policy Proposed Rule (“Proposed Remedy Rule”) published on July 7, 2023. CMS calculated that the overall

340B

The Proposed Remedy Rule outlines CMS’ plan to pay CEs a lump sum payment of the difference between what they were paid and what they should have been paid applying the statutory default rate of ASP + 6 percent at 42 U.S.C. 1395w–3a. Although the Proposed Remedy Rule is framed to be for 340B CEs, there is a component that will impact all OPPS providers for the next several years. CMS outlined a corresponding budget neutrality adjustment that will apply to non-drug items starting in CY 2025. CMS utilized an extended timeline in attempt to balance the interest of all hospital stakeholders. Providers will want to analyze the net impact of this payment reduction and submit comments on the methodology and proposed remedy to CMS.

CMS expects to finalize the

Proposed Remedy Rule prior to finalizing the CY 2024 OPPS rule this fall, with potential lump sum payments in late 2023 / early 2024. However, due to the budget neutral impact to all OPPS providers, it’s unclear if CMS will finalize the rule according to its intended schedule. We’ve summarized the major points from the Proposed Remedy Rule and areas where providers should consider submitting comments below. Comments are due by September 5, 2023.

Given the budget neutral adjustment presented by CMS, and the large volume of data used by CMS to project lump sum repayments, we anticipate significant feedback from a

variety of stakeholders impacted by the Proposed Remedy Rule.

Major Points from the Proposed Remedy Rule

1. CEs Can Except to Receive a Lump Sum Repayment for 2018 – 2021 Claims. CMS proposed to pay CEs lump sum payments, which were published by CMS in Addendum AAA. The total repayment amount for the lump sum accounts for $9B of the total $10.5B proposed. As proposed, neither CMS nor CEs would need to pursue adjusted coinsurance payments. CEs should verify the amounts published align

see Legal Matters ...page 13

Oncology Research

The Four C’s for Balancing Cancer Treatment and the Classroom

You’ve got notebooks, pens and pencils, an updated wardrobe, a new schedule. And cancer.

Heading back to school with all of the stresses that come with managing a cancer diagnosis is a daunting challenge.

No matter if you’re a student or parental guardian of someone in elementary or high school, college, or beyond, proper planning and support can help make it possible to create the right balance between successfully continuing one’s studies and undergoing cancer treatment.

Communication: Seeking support in the classroom

You don’t have change your major

to communications, but being an open communicator about your illness is one of the most important steps that students who have cancer can take. To get needed support, make sure teachers, administration, nurses or medical staff, and classmates (if you wish) are informed of your cancer care plan, any anticipated challenges you might be facing, and special accommodations you may need. Chances are they do not know all you are dealing with and will be more likely to offer assistance and understanding if you are able to be more transparent about your situation. Be sure to communicate your specific needs with trusted school staff, such as a counselor or student services teams. Find out what resources are available and put them to use to help you maintain academic success during treatment. Options such as tutoring, extensions on assignments or exams, or modified assignment requirements may be allowed, enabling students to keep up with studies without being

overwhelmed or penalized due to scheduled treatments.

Calendars: Be realistic with academic and treatment schedules

Cancer treatment can cause your energy level to fluctuate. You may have days where you feel like you can check everything off your school list, and other days when you don’t want to get out of bed. It is important to create a realistic schedule that allows time to rest and recover while still focusing on your studies. When you get your syllabus, plan ahead for assignments or exams that may fall on the same day as treatment. Think ahead to the possibility of unexpected health changes that could impact schoolwork and attendance in the classroom.

Make your health a top priority, allocating time for treatments, doctor appointments, and important self-care activities or therapies. Set realistic goals when it comes to your studies and share them with teachers and school administrators. It is okay to ask for help or even take a leave of absence if needed to prioritize your health.

Connections: Use technology keep up with assignments and classmates

The technology supporting education in and out of the classroom is vastly different than ten years ago. Technology can be a valuable and flexible learning tool. From online

see Oncology Research...page 13

Mental Health

Substance Use Linked to Long-Lasting Brain Changes and Cognitive Decline

Research Underlines the Relationship Between Substance Use and Significant Modifications To An Inhibitory Brain Circuit, Resulting In Decreased Cognitive Flexibility

An estimated 50 million individuals in the United States struggle with the challenges of cocaine or alcohol use disorders, according to the National Institutes of Health (NIH). Beyond the well-documented health risks, addiction to these substances detrimentally affects our cognitive flexibility, which is the ability to adapt and switch between different tasks or strategies. Although previous research has hinted at this connection, the underlying reasons for this cognitive impairment remain elusive. Cognitive flexibility is a crucial element in various domains of our life, including academic achievement, employment success and transitioning into adulthood. As we age, this flexibility

plays an important role in mitigating cognitive decline. A deficiency in cognitive flexibility, however, is linked to academic deficits and a lower quality of life.

A groundbreaking study led by Jun Wang, PhD, associate professor in the Department of Neuroscience and Experimental Therapeutics at the Texas A&M University School of Medicine, provides new insight into the damaging impact that chronic cocaine or alcohol use has on cognitive flexibility. The research, published in the journal of Nature Communication, emphasizes the role of the local inhibitory brain circuit in mediating the negative effects of substance use on cognitive flexibility. Substance use influences a specific group of neurons called striatal

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direct-pathway medium spiny neurons (dMSNs), with projections to a part of the brain known as the substantia nigra pars reticulata (SNr). Conversely, cognitive flexibility is facilitated by striatal cholinergic interneurons (CINs), which receive potent inhibitory signals from the striatum.

“Our hypothesis was that increased dMSN activity from substance use inhibits CINs, leading to a reduction in cognitive flexibility,” Wang explained. “Our research confirms that substance use induces long-lasting changes in the inhibitory communication between dMSNs and CINs, consequently dampening cognitive flexibility. Furthermore, the dMSN-to-SNr brain circuit reinforces drug and alcohol use, while the associated collateral dMSN-to-CIN pathway hinders cognitive flexibility. Thus, our study provides new insights into the brain circuitry involved in the impairment of cognitive flexibility due to substance use.”

Wang and his team are optimistic about the potential therapeutic applications of their findings and anticipate that they could inform new treatment strategies for substance-induced cognitive decline. The research receives support from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and an X-grant from the Presidential Excellence Fund at Texas A&M University.

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Healthy Heart Symptom Relief And Healthy Habits Are Top Goals For Treating Chronic Heart Disease

FEEL GOOD AGAIN

For the more than 20 million people in the U.S. with chronic coronary disease, a heart-healthy diet and lifestyle are the best ways to prevent worsening health, according to the latest joint guideline for chronic coronary disease

patient’s risk for future cardiovascular events;

• Symptom relief and quality of life are extremely important; and

• Team-based care is recommended for people with CCD including primary care clinicians in collaboration with cardiology specialists.

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from the American Heart Association and the American College of Cardiology.

The guideline, published in the American Heart Association’s flagship journal Circulation and in the Journal of the American College of Cardiology, affirms the value of a healthy diet, regular physical activity and not smoking, and updates several medication recommendations, according to the most recent scientific data.

Chronic coronary disease (CCD) is an umbrella term used to describe a variety of long-term vascular and heart conditions in which there is inadequate blood flow to or from the heart. It applies to people with chronic, heart-related chest pain; people who have had a heart attack, coronary stent or bypass surgery; and people who have evidence of reduced blood flow to the heart based on diagnostic testing.

The American Heart Association and the American College of Cardiology provide three principles for managing patients with CCD:

• Prioritize treatment based on a

Quality of life is an important consideration and includes evaluating treatment options from the patient’s perspective. The guideline recommends clinicians perform a comprehensive risk assessment at annual follow-up visits to evaluate all medical and social factors that are associated with heart health in patients with CCD.

Clinicians are advised to carefully review the risk assessment with their patients and educate them on symptom management and treatment options so they may actively participate in decisions about their care. In some cases, based on the risk assessment and conversations with the patient, clinicians may recommend therapies for symptom relief that may not prolong life or reduce the risk of cardiovascular events.

The guideline emphasizes coordinating care between cardiovascular and primary care professionals because the care team interacts with a person with CCD multiple times over a long period and treatment should be continually assessed. 

We’re all ready to feel good again, but for our food insecure neighbors there’s no vaccine to fight hunger.

The 1 in 5 Central Texas children at risk of hunger deserve a shot at a happy summer.

New clinical guideline from the American Heart Association and the American College of Cardiology highlights recommendations for diagnosing, treating and managing risks and symptoms for people with chronic coronary disease

Most

Cancer Patients

Men

Only 22% of Texas patients with early-stage pancreatic cancer received standard-of-care surgery to remove their tumors, researchers at UT Southwestern Medical Center report in a new study. The findings, published in the Journal of Surgical Oncology, are a call to action to improve treatment in the Lone Star State for this deadly disease, the authors say.

“We are failing nearly 80% of patients eligible for surgical resection, which can significantly extend survival or potentially even be curative in combination with chemotherapy,” said study leader Patricio Polanco, M.D., Associate Professor of Surgery in the Division of Surgical Oncology at UT Southwestern and a member of the Harold C. Simmons Comprehensive Cancer Center. “Many patients think

that this is always an incurable disease and don’t pursue aggressive treatment.”

Unlike many cancers, which have seen mortality rates decline significantly in recent decades, the prognosis for pancreatic cancer remains dismal, Dr. Polanco explained. Only 11% of patients with this disease survive at least five years, leading to more than 466,000 deaths worldwide each year.

For several decades, the standard of care and only curative treatment option for early-stage pancreatic cancer has been surgery to remove the malignant tumor, typically in combination with chemotherapy. This multimodal treatment has a median survival rate as high as 54 months, according to one recent study.

A previous report by Dr. Polanco

and his team found that patients receiving treatment at a facility designated by the National Cancer Institute or one accredited by the American College of Surgeons Commission on Cancer such as UT Southwestern’s Simmons Cancer Center were more likely to get the care recommended by national guidelines. These patients also had improved survival rates.

For the current study, Dr. Polanco and his colleagues gathered data from the Texas Cancer Registry (TCR), which collects information on cancer patients from every hospital in the state, to examine surgery rates in early-stage pancreatic cancer patients.

The registry showed 39,157 patients diagnosed with pancreatic cancer between 2004 and 2018, including 4,274 with early-stage disease who were eligible for surgery. However, over this study period, only 22% of these patients had their tumors surgically removed. Most alarmingly, the percentage of eligible patients who received this recommended surgery decreased over the study period, from 31% in 2004 to 22% in 2018, Dr. Polanco said.

Patients who received surgery were more likely to survive longer than those who didn’t, the results showed. Post-surgical patients lived a median of 26 months after diagnosis compared with only seven months for those without surgery. In findings similar to previous work, one of the factors most strongly associated with getting appropriate care was treatment at a

Hospital News

St. David’s South Austin Medical Center Names New Chief Operating Officer

role, she managed a $20.9-million capital expansion, increasing the hospital’s bed capacity by nearly 25% and expanding support service areas to accommodate the hospital’s growth.

“Megan has more than a decade of experience and a proven record of success in hospital operations and business development,” Charles Laird, chief executive officer of St. David’s South Austin Medical Center, said.

role, she provided administrative and financial oversight of hospital services, including wound care, dietary, environmental, biomedical, security, respiratory therapy, imaging, pharmacy and laboratory. Drake also managed several significant capital projects, including a surgical suite expansion that encompassed a new hybrid operating room, as well as construction of an electrophysiology lab to expand cardiovascular services.

St.David’s South Austin Medical Center has named Megan Drake as the hospital’s new chief operating officer. Drake assumed her role on June 1.

Before joining St. David’s South Austin Medical Center, Drake served as the chief operating officer at Heart Hospital of Austin. In this

“She is a strong addition to the leadership team at St. David’s South Austin Medical Center and will play a key role in further advancing the growth of the hospital.”

Prior to her time at Heart Hospital of Austin, Drake was chief operating officer at Shelby Baptist Medical Center—a 252-bed hospital in Birmingham, Alabama. In this

Prior to joining St. David’s HealthCare, Drake served as the western region chief business development officer for Prospect Medical Holdings, which owns 20 acute care and behavioral health hospitals in six states. Other leadership positions include market chief strategy officer for Valley Baptist Health System in Harlingen and Brownsville, acting chief operating officer and assistant chief executive officer of Cedar Park Regional Medical Center, administrative specialist and facility compliance officer at Lake Granbury

Medical Center, and administrative specialist at Northwest Medical Center in Springdale, Arkansas.

Drake earned a master’s degree in health administration from the Medical University of South Carolina in Charleston and a bachelor’s degree in biology from The College of Charleston. She is a member of the American College of Healthcare Executives.

St. David’s Healthcare Announces New Vice President Of Physician Services

Vyvyan Derouen, M.B.A., R.N., B.S.N., has been named vice president of physician services for St. David’s HealthCare and HCA Healthcare’s Central and West Texas Division. HCA Healthcare is St. David’s HealthCare’s national hospital operating partner.

As vice president of physician services, Derouen is responsible for leading the strategic direction and operations for nearly 500 employed physicians and advanced practice providers practicing at 150 locations across Central and West

Texas. She assumed her new role on June 26.

“With leadership experience across various provider groups and healthcare systems, Vyvyan will play a key role in maintaining and growing our physician base as our footprint expands,” David Huffstutler, president and chief executive officer of St. David’s HealthCare, said. “We look forward to the many contributions she will bring to our healthcare system.”

Derouen most recently served as the division vice president

of physician services for HCA Healthcare’s North Carolina Division, Mission Health, where she provided executive oversight to more than 110 locations and 650 providers. Prior to her role with Mission Health, Derouen served as vice president of physician services for the Tift Regional Health System in Tifton, Georgia.

Derouen also served in multiple leadership roles at Wellmont Health System in Kingsport, Tennessee, between 2011 and 2018, including vice president and chief administrative officer, executive director of cardiac

services, director of invasive cardiovascular services, and regional director of operations and development.

Derouen earned her master’s degree in business administration from Western Governors University in Salt Lake City, Utah, and she received a bachelor’s degree in nursing from McNeese State University in Lake Charles, Louisiana.

Less Is Best with Caffeine, Energy Drinks During Pregnancy

Millions of people drink coffee, soda, and/or tea daily, making caffeinated beverages the most commonly consumed stimulants in the world. Highly caffeinated energy drinks also have been a hugely popular pick-me-up for more than two decades, especially among younger adults and teens.

But pregnant individuals should be careful regarding energy drinks and their overall intake of caffeine, according to an expert at UT Southwestern Medical Center.

“Energy drinks contain varying amounts of caffeine, so check nutrition labels to understand how much caffeine and other ingredients they contain,” said David B. Nelson, M.D., Associate Professor of Obstetrics and Gynecology and Division Chief of Maternal-Fetal Medicine.

National guidelines recommend moderate caffeine consumption of less than 200 milligrams per day for anyone

pregnant or attempting to become pregnant. The American College of Obstetricians and Gynecologists says that level does not appear to be associated with miscarriage or preterm birth, but the relationship between caffeine consumption and fetal-growth restriction remains uncertain.

The caffeine content in energy drinks ranges from 50 mg to 500 mg in cans or bottles that vary in size from 8 ounces to 24 ounces. An 8-ounce cup of full-strength coffee contains just under 100 mg of caffeine, and the amount in sodas varies widely. For instance, a 12-ounce Coke has about 34 mg of caffeine, Diet Coke has 46 mg, and a regular Mountain Dew has 54 mg.

Small energy shots, usually sold at 2 fluid ounces, contain particularly high levels of caffeine – about 200 mg. Regulation of energy drinks, including content labeling and health warnings, differs globally, but the U.S. has some

of the most lax requirements. The Food and Drug Administration doesn’t regulate energy drinks, which are generally marketed as dietary supplements or conventional beverages.

The question of whether adverse pregnancy outcomes are related to caffeine is somewhat controversial, according to the latest edition of Williams Obstetrics, which reported that heavy consumption (about 500 mg daily) slightly raises the risk of miscarriage. Studies involving moderate intake – less than 200 milligrams daily –have not identified a higher risk. A recent study of patients from 10 states found that pre-pregnancy or first-trimester daily caffeine consumption was not strongly linked to birth defects.

Dr. Nelson said it can be difficult to curb intake of caffeine, and doing so can cause withdrawal symptoms including headache, fatigue and drowsiness, decreased alertness, depressed mood, irritability, and trouble concentrating.

“Gradual reduction in caffeine intake over several weeks before planning pregnancy, or when you find

out you are pregnant, can help prevent caffeine withdrawal,” said Dr. Nelson, a Dedman Family Scholar in Clinical Care.

If you’re looking for ways to boost your energy during pregnancy and would rather avoid caffeine, Dr. Nelson suggests trying these:

• Exercise regularly.

• Eat healthy foods.

• Drink plenty of water.

• Relax/take naps.

• Follow a regular sleep schedule.

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Excessive Heat and

Its Impact On Mental Health

Extremeheat this summer is affecting people across the country – mentally as well as physi-cally. While heat can make anyone irritable, the impact can go beyond that, especially for people with mental health conditions. A Baylor College of Medicine psychiatrist explains how heat af-fects mental health.

Excessive heat causes changes in emotions and behavior that can result in feelings of anger, irritability, aggression, discomfort, stress and fatigue. Heat alters those behaviors because of its impact on serotonin, the primary neurotransmitter that regulates your mood, leading to de-creased levels of happiness or joy and increased levels of stress and fatigue.

The most vulnerable groups affected by heat and mental health include people with preexisting conditions and people who use substances like alcohol. People who already suffer from stress, anger or anxiety will experience increased serotonin. If people use substances,

especially alco-hol, they need to be more hydrated. Combining substance use with heat requires even more hy-dration.

“All mental illnesses increase with heat because it results in more fatigue, irritability and anxiety, and it can exacerbate depressive episodes,” said Dr. Asim Shah, professor and executive vice chair in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor.

Signs of heat impairing mental health start with irritability, decreased motivation, aggressive be-havior and sometimes mental fogging. In worse cases, it can cause confusion and disorienta-tion. While avoiding the heat may not be possible, Shah recommends hydrating with electrolytes and keeping your head covered when going outside. In addition, pour some water on your head to cool down and try doing things in the shade. If you normally go for walks outside, move them inside by walking in the mall or a large space with air conditioning.

Age Well, Live Well

The Many Benefits of Intergenerational Connections

Whetherit’s volunteering, working on an art project or getting some exercise, spending time with a person of a different generation can help us learn new things, reduce social isolation and have fun.

Intergenerational programs that bring people of different generations together for a common purpose also increase social connection, which is an important part of aging and living well. It also has been proven to be good for your health.

Beyond the social connection benefits, Generations United highlights the many benefits that both older and younger people receive from intergenerational programs, including a stronger sense of community, reduced social isolation, increased self-esteem and

more. The American Journal of Public Health found that intergenerational activities that involve education and proper planning can be an effective way to reduce ageism.

Texas Health and Human Services recognizes the importance of reducing social isolation and has created several resources to help older adults and young people create intergenerational connections.

Texercise Connects, a free digital activity workbook, brings older and younger Texans together to interact, engage, create friendships, and foster growth and learning while having fun. Activities in the workbook focus on healthy behaviors (e.g., physical activity, nutrition and brain health) and creativity that can build and strengthen intergenerational relationships when performed together.

Ages United brings engaging intergenerational activities and

If you take medications, consult with your provider before mixing your dose with excessive heat. Some medications for mental health, such as lithium for bipolar patients, might not pair well with heat. Lithium goes through the kidney, so if you sweat more, levels of lithium fluctuate.

“If you are out in the heat and using lithium, levels may fluctuate. In that scenario, we have to be very careful and either adjust the dosage of lithium or avoid heat,” he said.

Climate changes, including droughts and extreme changes in temperature, can cause negative effects by increasing pollutants and allergens and worsening air quality. These worsen mental health issues like depression, anxiety or PTSD. Some studies show that exposure to any

natu-ral climate disaster can increase the risk of depression by more than 30%, anxiety by 70% and both by over 87%.

“Children are a vulnerable population due to their physical and cognitive immaturity. They are exposed to more pollutants and allergens as they spend more time outdoors,” Shah said.

Previous studies on emergency room visits explore hospital visits due to heat and mental health. A study in JAMA Psychiatry reported about an 8% increase in emergency visits due to the effects of heat on mental health. If you feel affected by severe heat, speak with your primary care provider or mental health specialist.

volunteers to residents who live in long-term care settings. The Ages United Guide offers step-by-step processes for creating meaningful activities. The guide provides learning opportunities, tips for reaching out to a long-term care facility, activity ideas and tools for evaluation. There is also a guide for virtual programming.

A companion to the Ages United Guide, the Ages United Activity Planner for Social Emotional Learning (SEL) assists high school faculty in creating intergenerational nursing

facility activities that align with SEL curriculum.

Explore the many ways intergenerational activities can add connection, joy and purpose to your life on the Aging Well Resources Form. Enter some basic information about yourself and select “Intergenerational” under the category menu.

Visit the Age Well Live Well webpage to learn more about aging and living well.

Legal Matters

Continued from page 3

with their internal claims data and comment on / dispute any apparent discrepancies. Keep in mind that some or all of the 2022 projection has likely been paid as discussed below. 340B CEs who submit comments to CMS regarding the payment amounts should request that future data regarding repayment amounts or the claims impacted remain confidential to the extent the CEs exchange claim-level detail.

2. CMS Has Reprocessed and Repaid Many 2022 Claims. CMS states that it already reprocessed most claims

Oncology Research

Continued from page 4

teaching platforms to more accessible educational materials and remote learning, technology is helping students communicate with teachers

with dates of service between January 1, 2022 – September 27, 2022 to be paid at ASP + 6 percent. This accounts for roughly $1.5B of the total $10.5B proposed remedy. CEs should verify whether they received accurate payment amounts at ASP + 6 percent for these claims.

3. CMS Continues to Push Budget Neutrality Argument. CMS proposed decreasing reimbursement for non-drug items and services to all OPPS providers, except new providers noted below, by 0.5% each year for the next 16 years until the increased amount paid to CEs between CY 2018 –2022 is sufficiently budget neutral. CMS spends a significant portion

and classmates even when they can’t be there in person.

This extends to making and maintaining connections with classmates who can provide much-needed emotional support and a sense of normalcy and belonging during your cancer treatment.

Celebrate: Small victories and big milestones

of the Proposed Remedy Rule discussing its obligation to remain budget neutral and how it will prospectively offset the lump sum payment. This budget neutral rate adjustment does not apply to CEs who enrolled in Medicare after January 1, 2018.

4. Payments from Medicare Advantage Organizations (MAOs) Not Addressed in the Proposed Remedy Rule. CMS had previously issued a memo to MAOs in December 2022, which explained that the non-interference clause prevents CMS from opining on reimbursement between MAOs and CEs because of the contractual nature of the relationship. Many MAOs have stalled issuing

You’re taking a journey that most of your teachers and classmates cannot imagine. Managing school and your health is not easy. Sometimes it is okay to celebrate even the smallest victory like finishing an assignment, making it to class two weeks in a row, or passing a test. Acknowledge each milestone as it can boost motivation and resilience.

Balancing schoolwork and cancer

repayments until CMS issued this Proposed Remedy Rule, so CEs should now resume pursuing repayments from MAOs based on the terms of their contracts. Of significance, the Proposed Remedy Rule clearly confirms CMS’s position that the default payment rate for all 340B drugs from 2018-September 27, 2022 is none other than the statutory ASP + 6 percent rate. MAO contracts apply the “then Medicare rate” or similar rate language should be closely analyzed in light of CMS’s recognition that there is no other alternative to the statutory ASP + 6 percent rate.

treatment can be a challenge, but the four C’s can help you manage both successfully. Know that you are not alone and your commitment to education while fighting cancer may very well inspire others on their own educational path. 

RAC Audit

Continued from page 1

documentation.

• Complex—medical record required.

CMS provides a sortable list of RAC audit issues on its Approved RAC Topics and Proposed RAC Topics pages. The information on these pages is updated regularly.

What Can You Do to Prepare for a RAC Audit?

Assess your risk for coding and billing issues by performing an internal audit of your own practices. Check that all billing codes are supported with appropriate documentation in the medical record. Additionally, follow these strategies when performing your audit:

• Consider hiring a contractor or assigning a knowledgeable member of your staff to review your coding and billing processes and develop a compliance plan.

• Identify coding and billing issues, track denied claims, look for patterns, and determine what corrective actions are needed to avoid improper payments.

• Review for circumstances that can lead to common coding and billing errors, including:

∆ Inadequately trained staff.

∆ Lack of time.

∆ Not following recommendations in the Federal Register.

∆ Not consulting the U.S. Department of Health and Human Services bulletins.

∆ Misinterpreting rules.

∆ New staff/new billing company.

• Include these areas in your assessment and monitoring plan:

∆ Review the categories of claims denied in earlier RAC audits.

∆ Keep abreast of notifications on the CMS website, including approved and proposed audit topics.

∆ Review the Office of Inspector General (OIG) annual Work Plan to identify audit areas.

∆ Monitor RAC progress on regional RAC web postings.

Potential Issues With EHRs

The OIG is studying the link between EHR systems and coding for billing. The concern is that some EHR systems may generate upcoded billing through automatically generated detailed patient histories, cloning (when examination findings are copied and pasted), and templates filled in to reflect a more thorough or complex examination/visit. Review these issues with your EHR vendor and determine if your EHR program has the potential to automatically upcode billing based on EHR documentation.

Fundamentals for Compliance

Establish compliance and practice standards and conduct internal monitoring and auditing to evaluate adherence. Medical coding and billing are complex, and staff must be knowledgeable about many areas pertaining to billing and reimbursement.

Be sure that your coding and billing staff understands local medical review policies and is knowledgeable

Pancreatic Cancer

Continued from page 7

hospital accredited by the American College of Surgeons Commission on Cancer.

“Most rural and remote places in Texas have access to local medical oncologists who administer chemotherapy, and often radiation oncologists, but not surgical oncologists specialized in pancreatic cancer

surgery,” Dr. Polanco said.

He noted that better treatments for pancreatic cancer are needed, and several are currently in development.

“But there is a treatment described several decades ago that can actually cure pancreatic cancer and dramatically extend survival, and that is surgery,” he said. “While we are spending millions

about practice jurisdictions. Staff must stay current on coding requirements, keep up with industry changes, understand the denial and appeal processes, and be able to identify resources for support.

The RAC auditor can request a maximum of 10 medical records from a provider in a 45-day period. The time period that may be reviewed is three years. Responses are time sensitive, and significant penalties may result if they are not handled properly. RACs are paid on a contingency basis for overpayments and underpayments.

If a recoupment demand is issued and you agree with it, you have the choice of paying by check within 30 days, allowing recoupment from future payments, or requesting an extended payment plan.

You can appeal if you do not agree with the audit findings. Do not confuse the RAC Discussion Period with the appeals process. If you disagree with the RAC determination, detail why you disagree in a discussion letter and file an appeal before the 120th day after the demand letter. Send correspondence to the RAC via certified mail.

of dollars to find the next new drug, we should spend at least the same amount and effort to ensure that every patient with pancreatic cancer is seen and assessed by an expert team of physicians to increase the awareness of this potentially lifesaving surgery.”

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2.00 AMA PRA Category 1 Credit(s)™

FOOD AND HOUSING INSECURITIES: Quick Courses

Join more than 100,000 medical professionals who get free CME with Texas Health Steps Online Provider Education. Choose from a wide range of courses relevant to your practice, including short tutorials and quick courses on topics like Medicaid guidelines, ethics and mental health—available 24/7. Learn more at TXHealthSteps.com.

Content on the Texas Health Steps Online Provider Education website has been accredited by the Texas Medical Association, American Nurses Credentialing Center, National Commission for Health Education Credentialing, Texas State Board of Social Worker Examiners, Accreditation Council for Pharmacy Education, UTHSCSA Dental School Office of Continuing Dental Education, Texas Academy of Nutrition and Dietetics, Texas Academy of Audiology, and International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for some online content.