Recovery Audit Failure

A multitude of investigations were conducted in response to the 2014 VA Scandal with reports and audits showing manipulation of records, long wait times, delays in treatment and overwhelmed caseload by VA practitioners (Wikipedia, n.d., para. 3-7). There are also concerns about the VA’s lack of accountability once

The Recovery Audit Programs (RAC) is to identify any Medicare collection that is under any detection and collection of overpayments that are made on claims of health care services that are provided by Medicare beneficiaries, and to identify any payments that are provided so that CMS can take any actions that can prevent future improper payments in all 50 states. RAC programs is a successful program that utilizes the recovery Audit to identify ant Medicare overpayments and underpayments to health care provider to suppliers in selected states. The demonstration that has been ran between 2005 and 2008 has resulted in over $900 million in overpayments that has been returned to the Medicare Trust Fund and there has been $38 million in underpayments that has been returned to the health care providers. This has resulted in Congress to require the Secretary of the Department of health and Human Services to have a permanent and national Recovery Audit programs to help on overpayments that are associated with services for which payment are made under Medicare part A or B Which is the Social Security Act. For every Recovery Audit has a responsibly to identify any overpayments and underpayments that is within ¼ of the country.

In my role with Liberty Mutual, I drove adoption of Medicare reimbursement models through public affairs involvement with multiple state workers' compensation committees seeking to update their reimbursement schedules in response to the implementation of ICD-10 coding requirements in October of 2015. With the state workers’ compensation authorities seeking to adopt CMS reimbursement type models, my involvement was directed at securing the inclusion of specific CMS rules governing correct coding and reimbursement practices including National Correct Coding Initiative Guidelines (NCCI), Medical Unlikely Edits (MUE), along with the Resource Based Relative Value System (RBRVS) for reimbursement rate setting.

The American Health Care system needs to be constantly improved to keep up with the demands of America’s health care system. In order for the American Health Care system to improve policies must be constantly reviewed. Congress still plays a powerful role in public policy making (Morone, Litman, & Robins, 2008). A health care policy is put in place to reach a desired health outcome, which may have a meaningful effect on people. People in position of authority advocates for a new policy for the group they have special interest in helping. The Health care system is formed by the health care policy making process (Abood, 2007). There are public, institutional, and business policies related to health care developed by hospitals, accrediting organizations, or managed care organizations (Abood, 2007). A policy is implemented to improve the health among people in the United States. Some policies

Our healthcare system needs major restructuring. Major improvements needs to begin with "all health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States", (Crossing the ……, 2001).

Health care fraud and abuse is a significant contributor to high health care spending, resulting in the wasteful spending of health care dollars. The Federal Bureau of Investigation (FBI) and National Health Care Anti-Fraud Association (NHCAA) estimates that 3 to 10 percent of health care dollars are lost to fraud and abuse (Federal Bureau of Investigation, 2010). Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to themselves or some other person (Ryan, 2006). Bloomberg reports health care expenditures are rising faster than the rate of inflation and spending in the US has nearly doubled in the last decade and one-half of health care

Ultimately, these regulations of the ACA have effectively solved many inefficiencies within the healthcare system. One of the biggest problems was the large amount of government spending due to Medicaid. However, the Accountable Care Organisation

This newer reimbursement system has been a topic of contention amongst a large portion of the professional medical community due to the perceived unfairness that it brings in certain situations where a patient must be readmitted and, as a consequence, the primary care providers may not be reimbursed for the readmission regardless if they were responsible. With the introduction of the Affordable Care Act in 2010, further criteria such as the Readmissions Reduction Program have been added that determines the eligibility of a primary care provider being reimbursed through the Medicare/Medicaid program. These new requirements have led to new avenues of contention amongst healthcare professionals and, in some cases, new avenues for fraud and patient discrimination.

On October 1, 2013 CMS has implemented a two midnight rule. If a patient is not in the hospital over two midnights the claim will not be eligible for payment under Medicare Part A (Pahuja, 2014). The physician must document and prove necessity for a two night stay. The American Hospital Association and three hospitals have sued Medicare based on ethical standards of RAC. The claim is that RAC auditors are paid based on the funds recovered from hospital audits. The push to pay auditors a flat fee, eliminating the unsubstantiated over riding of a physician decision in order to increase the amount of dollars

In the past several years, there have been several changes in economic policy at federal and state levels. The two economic policies that present to be the most precedent for healthcare leaders with concern to facility reimbursement are the Affordable Care Act (ACA) and the switch from volume to value reimbursement. First, there is the ACA policy, which have affected healthcare facilities and their reimbursement methods. In fact, ever since this policy was implemented, provider reimbursement has started to decrease in terms of fee-for-service payments (The Common-Wealth Fund, 2015). In other words, the intention of this policy was to provide budget relief to the government payers as well as giving providers an incentive to provider patients with great quality of care.

The Affordable Care Act was enacted to improve health care and to lower health care cost in America. The ACA developed different strategies to meet these goals called the “pay for performance” programs. These strategies are aimed at the different providers to improve quality care. The strategy that I selected

Affordable Care Act – Medicare’s Readmission Reduction program Target Group: Valley Hospital Healthcare Policy Analysis Paper Washington State University Sheetal Wadhwa Executive Summary: Healthcare in the U.S is most expensive than any other developed country. The U.S spends far more on per capita as compared to any other developed. U.S scores low on many outcome measures, inefficiencies and wastes and quality measures as compared to other countries. The Patient Protection and Affordable Care Act is developed to strengthen these failures in the health care system. The U.S healthcare is transforming care from volume based reimbursements to value based payments. The healthcare law works around providing more patient centered care and better preventive care. One of the payment reforms with Obamacare is to penalize the hospitals with high readmission rates for the three conditions – Acute Myocardial Infarction, Heart Failures and Pneumonia.

Introduction to Health Care Finance (HCA 240) Analyze Contemporary Health Care Issue According to the Federal Bureau of Investigation (FBI) “health care fraud costs the country an estimated $80 billion dollars a year” ("Health Care Fraud," n.d., p. 1). Because health care costs continue to rise more rapidly than the rate of inflation the threat of health care fraud continues to rise. The Affordable Health Care Act has put new policies in place to identify and stop health care fraud. The FBI along with other government, insurance, and public agencies have joined together to combat fraud at every level. New rules in identifying, investigating, and prosecuting fraud before payments are made to medical providers could save billions of

Implementation of The Affordable Care Act has addressed some issues surrounding HAIs. For instance, section 3008 of ACA recognized the HAC or hospital acquired condition in the Reduction Program to further reduce HACs and improve patient quality.

In the wake of the 2016 presidential election, concerns have been raised regarding the Republicans’ desire to repeal the Affordable Care Act, informally referred to as Obamacare. The ACA was originally enacted into law in 2010 and has been annually provisioned to expand its ability to not only improve the nation’s access to health care, but also to reform the health care delivery system. Through the ACA, private and public insurance has become more available and affordable, new health care delivery models have improved quality of care, and several workforce policies have made primary care a more desirable profession for medical students.