RAC VS. ONCOLOGY A COALITION-BUILDING PROTOTYPE TO QUELL

ONEROUS ATTACKS

Dane J. Dickson MDPresident Idaho Society of Clinical Oncology

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Sun Tzu 孫子 – The Art of War

“If you know the enemy and know yourself, you need not fear the result of a hundred battles.”

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Know yourself Remember

FDA LabelsGuidelines (NCCN, ASCO, etc.)Published Literature (not abstracts!!!!)Standard of Care

Payment for an issue doesn’t necessarily mean that the payer agrees with your medical decision

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RAC Demonstration Program 2003 Medicare Modernization Act (MMA) –

Section 306 3-year demonstration program using

Recovery Audit Contractors (RACs) to detect and correct improper payments in the Medicare FFS program

Initially started in states of New York, Massachusetts, Florida, South Carolina and California

Ended on March 27, 2008

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Results of the 3 year project

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Results of the 3 year project

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Results of the 3 year project

• Only 14% of audits appealed

(with a 33.3% chance you would win).

• If you are a RAC you have a 95% success rate.

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Results of the 3 Year Project Lessons Learned:

“Claim RACs are able to find a large volume of improper payments.”

“Providers do not appeal every overpayment determination.”

“Overpayments collected were significantly greater than program costs.”

…“It is possible to find companies willing to

work on a contingency fee basis.”

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Results of the 3 year Project “The RAC demonstration had limited

financial impact on most providers. . .those repayments were small in comparison with the providers’ overall income from Medicare.”

“. . .the RAC . . .cost only 20 cents for each dollar

collected”

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Results of the 3 year Project

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Updated Statement of WorkSept 1, 2011 Added a 3rd audit category

Semi-automated Review“To be used in [cases where] a clear CMS

policy does not exist but in most instances the items and services as billed would be clinically unlikely or not consistent with evidence-based medical literature.”

Prior to this, only Automated and Complex Reviews

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Updated Statement of WorkSept 1, 2011

RACK – Medieval Torture Device

RA – Egyptian Sun Deity

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RAC Regions Follows the DME Regions for Medicare Region A:  Performant Recoveryhttps://www.dcsrac.com/Default.aspx Region B:  CGI Federal, Inc. https://racb.cgi.com/default.aspx Region C:  Connolly, Inc. 

http://www.connolly.com/healthcare/Pages/CMSRacProgram.aspx

Region D:  HealthDataInsights, Inc.http://www.healthdatainsights.com/rac.htm

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CMS – RAC Regions

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Semi-Automated Review

8/30/2012

“This letter is notify you that the Recovery Auditor HDI believes that Medicare has potentially made an overpayment to you. . . .Pegfilgrastim should not be administered during the 24 hours after chemotherapy.”

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How RACs Determine Major Audits

Audit Item

CMS

Proprietary Data

Review

“Low Hanging

Fruit”

RAC

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Notification of Audit Item

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Finding RAC Audit Items Region Ahttps://www.dcsrac.com/IssuesUnderReview.aspx Region Bhttps://racb.cgi.com/Issues.aspx Region Chttp://www.connolly.com/healthcare/pages/ApprovedIssues.aspx Region Dhttps://racinfo.healthdatainsights.com/Public1/NewIssues.aspx

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Simplifying the RAC Process

RAC Request

Provider Rebuttal

Appeal 1 MAC

Appeal 2 QIC

Appeal 3 ALJ

Appeal 4DAB

Appeal 5 US District Court

MAC: Medicare Administrative ContractorQIC: Qualified Independent ContractorALJ: Administrative Law JudgeDAB: HHS – Departmental Appeals Board

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Sun Tzu 孫子 – The Art of War

“. . .in war the victorious . . .only seek battle after the victory has been won, whereas he who is destined to defeat fights first and then looks afterwards for victory.”

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Objectives, Strategies, and Allies

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Objectives/Strategies

RAC Provider Rebuttal

MAC

CMS

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MAC to CMS to RAC

“Stop Audit”1

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MAC

“Overturn RAC”2

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CMS

“Stop Audit”3

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RAC

“Unreasonable”4

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Escalated Strategies (If Needed)

RAC ProviderMAC

CMS

Share Holders

CongressPatients 5

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Congress

“Bad Policy”5

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6Corporate Leadership

“Very bad PR”6

Performant: PFMT CGI: GIBConnolly: PrivateHDI: HMSY

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Business of RAC HDI Acquired by HMS

Holdings 11/7/2011 Announced 3 month increase of

25% vs. 10% for Dow

Approx. increase in market value

$670 Million

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“Why bring a nuclear missile to a knife fight?” Inherent conflict of interest of the RAC Defining “not consistent with medical literature” Personal Experience/Concerns with RAC

Loss of Records○ Inability of RAC to find records

Faxed Certified mail

○ Response not received = automatic denial, and no further work needed to be done by RAC (MAC now does the work)

Over 3 year look back on audit item○ Surprising given complete access to billing and payment

records

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Unified Oncology CoalitionIdaho Oregon

Utah

Alaska

Montana

Nebraska S. California

Washington

State Societies

COA

CMSMAC

PRIT

ASCOCPC

SAC

RAC

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States/State Societies Alaska - Denali Oncology Group Southern California (MOASC) Idaho Society of Clinical Oncology (ISCO) Montana – Frontier Cancer Nebraska Oncology Society (NOS) Oregon Society of Medical Oncology (OSMO) Society of Utah Medical Oncologists (SUMO) Washington State Medical Oncology Society

(WSMOS)

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COA/Administrators COA

Amazing communication and mobilizationRapid response and focused perspectiveInvolved CMS/PRIT

State AdministratorsLogistic supportCommunication and direction

THANK YOU!

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American Society of Clinical Oncology

Although physicians clearly do not like to receive letters from the RACs, theconcerns described below are well beyond such general frustrations and involve very specific, significant flaws with this particular audit. Any one of these concerns warrant suspension of the audit. Especially given the implications when these issues are taken in combination, we urge CMS to intervene and suspend the ongoing RAC audit in Region D and to ensure that the same audit is not pursued in other regions of the United States.

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CMS - PRIT Physicians Regulatory Issues

Team Small group since 1999

“. . . working hard to identify issues, chase them down, and create solutions that are truly tangible to the practicing physician.”

CMS Position Suffers from lack of funding

and low visibilityWilliam D Rogers MD

Medical Officer CMS and Director Physicians Regulatory Issues Team

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MAC - Noridian Medicare Administrative

Contractor – Jurisdiction F and Minnesota

After receiving information from the State SocietiesContacted CMS – halted audit“We are going to overturn them

all on appeal any way. . .”

“GET INVOLVED!”Bernice Hecker MD

Contract Medical Director Parts A&BNoridian Administrative Services

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Noridian – Coverage Letter“Based on the evidence, the administration of same-daypegfilgrastim has become an accepted standard of care and in particular, in situations where patients are believedto be a higher risk of potential non-compliance with day 2 administration.

“. . .the administration of pegfilgrastim before the traditional 14day window has become an accepted standard of care to maintain dose-density or reduce neutropeniccomplications in regimens with substantial myelosuppression.”

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? Final Results of Audits RAC contacted our practice saying that

our appeal was accepted and no overpayment existed

This included the audit that they lost Most practices had all same day

pegfilgrastim audits overturned but . . . Nebraska fights on – ? If RAC reviewed,

? If MAC reviewed, ? next steps

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Why does one RAC Drug Audit Matter?

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COA/ISCO National Post-Payment Review Survey (1 of 3)Informal, non-scientific survey written by ISCO and sent by COA (thank you Mary Jo Wichers and Bo Gamble) to practice administrators nation wide. Completely voluntary with no follow up.

# of respondents         26States Represented     19

How Frequent are Post Payment Reviews in the Following Areas:            Chemotherapy  62%            WBC 31%              RBC 15%              Anti-emetics 15%(Note: each area independent – some practices have received audits in multiple areas)

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COA/ISCO National Post-Payment Review Survey (2 of 3)Who is conducting the audits?Medicare 70%Medicaid 3%Private Insurers 27% How often has the audit been performed even when a pre-authorization was obtained:     34%

How often was the following successful in retaining payment:Provide Records 64%Showing guidelines or compendia 27%Providing clinical trial information 17%Talking to Medical Director 6%Legal Action 1%

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COA/ISCO National Post-Payment Review Survey (3 of 3) When a claim had to be repaid, how often was the following the reason for the repayment:Lack of unbiased review by payer                      35%Mistake by Billing or Coding 28%Other                                                                         19%Use of therapy outside of guidelines or compendia 14%Limited research                                                         5%            Number of man hours spent on post payment review/month             20 hoursAverage days until resolution of a single review                                53 days

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Where do we go from here?

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Using an Unified Oncology Coalition to Drive Policy

State Societies

COA

National (CMS)

ASCOSAC

Statewide (Private Insurers)

Patients and

Advocates

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Possible Areas to Address Pre-authorization

Develop a standardized method of authorization for all insurers

Simplify the process – especially with on-label drug usage

Quality MeasuresDevelop standard methodology of

measuring qualitySimplify the process

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Possible Areas to AddressEstablishing National Rules for Drug Audits

Private Insurers:1. If pre-authorization was given – then this claim shall never be subject to post-

payment review.  2. If pre-authorization becomes even more arduous, then there shall be an

expectation that payers will reimburse this administrative burden.3. Any disputed claim should be subjected to an independent review board.

Medicare:4. Any RAC audit item that deals with a “standard of care” issue – should be

reviewed and agreed upon by an independent society before CMS approves it.

Both:When dealing with the appropriate use of drug:5. FDA Label trumps everything else, NCCN Drug Formulary/etc. next,

NCCN/ASCO Guidelines next.6. Sequencing of drug shall not be a look-back audit item.  If a payer wants to

look at sequencing (i.e. pathway) it should be established and communicated up front.   

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“If we don’t lead, we will concede.”

Summary