Medicare

Compliance 360, providers of a governance, compliance, accreditation, and audit software solution, have just added a new module to the already impressive array of features.  The new module helps healthcare organizations navigate the increasingly important world of claims audits.  As many of our readers will know, CMS rolled out a pilot program to attempt to get back a portion of the billions lost to overstated Medicare Claims through a program known as "Recovery Audit Contractor" ("RAC").  As the company's Web page on the module notes, the new module "has been designed for managing a wide variety of claims audits including the Medicare Recovery Audit Contractor (RAC) program, Medicare Program Safeguard Contractor (PSC) audits, Medicare Comprehensive Error Rate Testing (CERT) audits, Medicaid Integrity Contractor (MIC) audits, Medicaid Fraud Control Unit (MFCU) audits and other forms of claims audits."  Click here to see the full description of the audit.

In the 5-minute video, below, I talk a bit about how I came to know Compliance 360's compliance and accreditation software in some of its earliest iterations, and why I continue to recommend the product and the people to my clients who need a comprehensive compliance software solution.  

To the tortoise goes the race.

Last month, URAC achieved “deemed status” as a recognized accreditation organization (“AO”) in CMS’s Medicare Advantage (“MA”) program. What this means is that URAC-accredited health plans and health networks who also seek URAC’s accreditation under its “Medicare Module” will be deemed to be in compliance with significant aspects of CMS’s MA program without the need of regulatory oversight in those areas.

URAC joins NCQA in this “deemed status” category. JCAHO and AAAHC had that status for a while, but no longer do, ceding the turf to the “big two”.

All I have to say is, “phew!”.

URAC made a strategic decision not to jump right into the fray when the program was announced several years ago, but launched its efforts in late 2003. For much of the process, I consulted as project manager and worked closely with URAC’s staff on the creation of the crosswalk comparing URAC’s health plan and health network standards to the CMS regulations, then writing the Medicare Module to fill in the gaps where URAC did not have a standard to correlate with specific regulatory requirements.

So, some of the delay was the result of this executive decision at URAC. However, oddly, some of the delay is directly attributed to the Medicare Modernization Act (“MMA”). It just happens that URAC’s timing was bad, colliding with the enormous pressures on CMS’s staff to implement the prescription drug program mandated by the MMA. URAC’s application simply sat on overworked regulators’ desks throughout the summer and fall of 2004, so long, in fact, that the window of opportunity for CMS to conduct the site visit that is part of the AO deemed status process closed. URAC was forced to resubmit its application when things cooled down at CMS and they were able to coordinate the requisite site visits with a beta applicant.

Things were further slowed down when changes in responsible personnel at CMS seemed to lead to changing review requirements. Language and processes that had been approved in 2004 were no longer good enough in 2005. URAC’s staff navigated the changing landscape skillfully, completed the site review process in March, and crossed the finish line in June.

In the weeks since the approval, calls have started to come in, both to URAC and to Integral Healthcare Solutions, with inquiries about the application process.

Sounds like some URAC applicants consider it to have been worth the wait!