The AMA’s complaints against HCFA
April 1, 1999
The AMA’s complaints against HCFA
Here are some of the specific complaints the American Medical Association made against the Health Care Financing Administra tion in recent written comments to Congress
• Program integrity. The AMA is concerned about what it calls HCFA’s "overly zealous implementation of its policies in addressing waste, fraud, and abuse." The AMA says HCFA continually fails to distinguish between knowing and willful fraud and legitimate differences of opinion regarding proper coding.
HCFA’s sole response to a broad range of complex problems has been to address each one in an aggressive and punitive manner, the AMA says. In response to the current environment, carriers are forced to pursue aggressive tactics. In this "gotcha" atmosphere, both patients and physicians suffer, says the AMA.
In response, providers are asking HCFA to increase its education efforts and urge carriers to work with physicians to correct problems rather than nail physicians for honest mistakes.
• Post-payment audits. "These audit procedures lack fundamental fairness," the AMA said in its comments, presented to the health subcommittee of the House Ways and Means Committee. To avoid a total disruption of their practice, as well as expensive legal bills, physicians frequently are forced into civil settlements without the ability to appeal, the AMA says. In many cases, auditors extrapolate hefty fines from a small sample of claims, critics claim.
"We recommend that the Administration temper its rhetoric and refine its program initiatives so that those physicians honestly participating in the Medicare program are not subjected to the federal government’s overly aggressive and punitive approach," the AMA told Congress.
• Annual carrier performance reviews. In determining whether the Secretary of Health and Human Services will contract with a carrier to administer the Medicare program, the Secretary should consider physician input in evaluating whether to contract with that carrier.
• "Black box" edits. The AMA says providers should have substantive input before HCFA implements the use of any commercial "black box" software for code editing/bundling. These "black box" methods do not draw on physicians’ expertise and practical knowledge of the services billed. Their use distorts the billing process, discourages correct coding, creates inefficiencies, and often results in physicians being paid less than the physicians’ cost of providing the service.
• Carrier extrapolation techniques. The practice of determining Medicare’s estimated overpayment to a physician based on a statistical sampling of a small number of disallowable claims is inequitable. Provider groups are demanding that carriers identify a problem and provide the physician with an opportunity for a telephone discussion or a face-to-face meeting, in which the carrier must adequately explain how to correct the billing problem in the future. If a physician’s future billing activities are found in error, HCFA should only recoup overcharges based on actual errors found.
• Carrier assistance. Medicare carriers should be required to give physicians, upon request and without charge, carrier-generated information needed to submit claims. This information includes the identifier number or other code of a referring physician, a list of maximum allowable charges, and coding protocols needed by physicians to submit a claim for payment or to respond to a carrier inquiry.
• Fining carriers for violating regulations. Carriers that violate Medicare policy should compensate aggrieved individuals. Any physician who is aggrieved by the failure of a carrier to carry out Medicare policy, and who can prove that he or she suffered damages of at least $500 as a result of the failure, should be permitted a hearing on compensating that physician.
• Compliance manual. HCFA should develop and provide a Medicare compliance manual to all participating physicians without charge.
• Electronic claims. Medicare should fund toll-free lines used for the submission of electronic claims to the program. Payment for use of a telephone line to submit electronic claims to Medicare is a de facto user fee. Medicare formerly provided this service at no charge.
• Claim review parameters. Carrier medical review screens or associated parameters should be released beforehand for providers to review before claims can be denied.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content