Medicare “waste” and “improper payments” are no strangers to the governmental spotlight. This time it shines on them in the form of legislation just introduced by Sen. Charles Grassley (R-IA) called the Fighting Medicare Payment Fraud Act of 2009.
This bill is one you may want to watch closely. The reason: it would allow payment delays of up to one year if the government suspects waste, fraud or abuse – essentially circumnavigating current prompt payment rules.
“Because of this prompt payment rule, the government puts itself in a position of having to pay and chase Medicare fraud, instead of working to prevent it in the first place,” Grassley says in a press release introducing the bill. So, Grassley proposes to “…give the Secretary of Health and Human Services authority to extend the time period in which payments must be made under the prompt payment rule if the Secretary determines there is a likelihood of fraud, waste or abuse. With this additional time, the Secretary would be required to conduct more detailed reviews of the claims in question to make sure they are supposed to be paid.”
Theoretically, of course, this bill makes perfect sense. Who can argue against proactively fighting Medicare fraud and waste, especially with some estimates saying it costs us $60 billion annually?
The devil, as always, is in the details. Few providers intentionally seek “wasteful” Medicare spending. But does a provider risk heightened scrutiny if he consistently bills level 4 office visits that government auditors believe warrant only a level 3? Where will the line be drawn in determining the “likelihood of fraud, waste or abuse”? That’s what we don’t know, and need to watch.
If this bill were to be passed – which is far from a done deal at this very early stage – it would certainly intensify the importance of clean claims submission to your cash flow. Playing devil’s advocate, let’s say Medicare were to question some of your level 4 office visits. Consider the effect of payment potentially delayed as long as a year, with the government allowed “whatever time is necessary” to conduct its claims review.
Is it worthwhile to try to combat inappropriate and erroneous Medicare payments? Absolutely – no one would dispute it. Just be aware that prevention of unintended consequences rests in crucial details.
The good news, of course, is that you can be proactive. Whether or not this particular bill becomes law, there are many tools available that you can use right now to ensure each claim, to every payer, is scrubbed clean prior to submission. The immediate benefit to your denial and rejection rates is obvious – the future benefit to reducing any potential red flags may be every bit as profound.