As enacted in the Patient Protection and Affordable Care Act, states are required to have established operational health benefit exchanges by January 1, 2014, or the federal government will implement one for them. These exchanges will allow individuals and small businesses to buy health care coverage and are expected to add approximately 30 million currently uninsured persons to the health insurance market. Most of the health plans that will be offered on such exchanges will be managed care plans with networks of participating providers. Thus, the resulting new business will be covered by hospital, physician, and other provider participation agreements with such managed care plans.
By now, every American who pays any attention to the news is aware that the Supreme Court of the United States has upheld essentially all of the Obama administration's Affordable Care Act. We have posted a copy of the lengthy opinion, concurrence, and dissent on our website. For now, we should be focusing on what the case of National Federation of Independent Business v. Sebelius actually will cause to occur.
As part of continued efforts to expand the Medicare Recovery Audit Contractor (“RAC”) program, the Centers for Medicare & Medicaid Services announced in November 2011 the implementation of a demonstration project that will allow RACs to conduct prepayment reviews on certain types of Medicare claims that historically have resulted in high rates of improper payments.
The prepayment review demonstration project will focus these efforts in 11 states—seven of which were selected because they have significant populations of fraud- and error-prone providers, and four states were selected for having relatively high claims volumes of short inpatient (“one day”) stays. The demonstration project is expected to begin in the summer of 2012.
Providers should consider that prepayment review, through implementation of this demonstration project, may become the new model for RAC review, in line with the government’s theory that it is easier to stop money from getting out than to “pay and chase” improper payments once they have been made. As such, providers must take necessary steps to assess, analyze, and, as needed, make investments to improve internal auditing and monitoring policies, procedures, and processes.