Guest Columns

Payment accuracy is a calling

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Kristin Walter
Kristin Walter

Careers in the healthcare field span such a wide variety of applications – with some passionately drawn to provide care for vulnerable patients like children or the elderly, while others are attracted to fast-paced, hospital settings. While those more traditional career paths are still in high demand, others are drawn to leverage their clinical skills to try and protect patients from the high healthcare costs that can sometimes cause financial devastation.

Experienced nurses, therapists and physicians can become disheartened watching patients struggle with enormous medical bills – sometimes having to pay out-of-pocket for uncovered services that may not have even been necessary. These medical professionals understand what's at stake when we don't get medical billing right. As a result, many have pursued careers that allow them to work hard to ensure that healthcare costs are kept in check, providers are appropriately compensated for their important work and our nation's health entitlement programs are operating efficiently and sustainably.

These recovery auditors are employed not only by the Medicare and Medicaid programs, but also by our nation's private insurance companies to ensure that patients are receiving the proper care, in the proper settings and that those services are billed correctly according to payment policy. Medicare RAs, in particular, are tasked with evaluating a very small percentage (0.5%) of medical claims on a post-payment basis, to ensure that Medicare billing rules and policies are followed. The Centers for Medicare & Medicaid Services also assigns which billing areas RAs can review.

RAs are required to have a very particular set of skills – often the combination of decades of clinical experience coupled with deep case management expertise. The auditors I've met had more than 20 years of experience working as registered nurses in a clinical setting before they moved into quality of care or case management roles. Recovery audit nurses, therapists and certified coders partner with a physician medical director — who also has more than 20 years of clinical experience, board certifications and senior leadership positions at major hospitals and universities — to round out a special team of experts working together to ensure billing accuracy.

Medicare RAs are passionate about keeping medical costs in check to preserve coverage for the more than 55 million Americans who rely on the program for their health. That's why ensuring that patients receive the right level of care in the right setting matters – getting Medicare billing right will help extend the life of the Medicare Trust Funds now and in the future.

The effective and efficient use of our tax dollars absolutely plays a role in whether Medicare will be able to remain financially viable in the future. Due to the expected influx of new beneficiaries and increasing healthcare costs, Medicare is in serious financial jeopardy. In fact, in just 10 years, Medicare Part A will scale back coverage to just 87 percent of what's covered today due to the depletion of the Trust Fund.

This leaves many Americans wondering - what will Medicare look like when it's our turn to retire? How much more should I save for retirement now to ensure that I can pay the higher out-of-pocket costs expected due to less Medicare coverage in the future?

As the new administration works to tighten the federal budget, attention is turning back to reducing Medicare improper payments. The program has lost $166 billion to medical billing mistakes over the past four years alone. We're talking about care simply billed to the wrong codes; claims being double or triple billed; medication billed for ten times the amount administered; and services provided to patients that were not necessary.

It's an exponential effect. Multiply a few simple billing mistakes by the more than 5,500 hospitals across the country, the more than 15,000 nursing homes, the thousands of durable medical equipment providers and other practitioners billing Medicare each day across the nation, and it's easy to see how billing errors can cause a loss of more than $40 billion each year.

The next time you envision your Medicare claims being reviewed by a recovery auditor, know that they are being carefully analyzed by smart, talented medical professionals just like you who are experts in Medicare payment policy. They are your neighbors, your friends, your past colleagues, all working hard to educate providers about proper billing practices and serving as the first line of defense to preserve the solvency of the Medicare program for all of us, so that it's still in place when it's our turn to enroll.

Kristin Walter is a spokeswoman for The Council for Medicare Integrity.




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Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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