Is 1599 the New LTC Lucky Number? - SpecialtyRx
December 19, 2017
Is 1599 the New LTC Lucky Number?

Many Medicare providers are no
longer subject to recovery auditing.

So how does the new CMS
sliding scale affect your facility?

Starting last year, the Centers for Medicare and Medicaid Services changed their auditing requirements, effectively reducing the percentage of total payments reviewed to .5% per facility. In addition, the new ADR (Additional Documentation Request) policy will soon subject providers to a sliding scale, rewarding LTCs that comply while penalizing those who exhibit frequent billing errors. All’s fair in the land of Medicare, right? Well, the government’s revamped model has done more than shake up the current audit system. Experts have discovered an unintended loophole, wherein any provider submitting under 1599 claims per year will be exempt. That’s right: zero billing reviews.

The great escape

in numbers


Percentage of a facility’s claims reviewed during auditing


Max number of claims you can submit to be exempt


Total taxpayer dollars lost since 2012 due to billing inaccuracies


Total lifetime overpayment funds returned to the Medicare Trust Fund

*Data compiled by Kristin Walter of The Council for Medicare Integrity

Exemption: blessing or curse?

Many industry professionals are worried about the long-term impact of the new CMS methodology. The Medicare system has always been fraught with problems, and in the case of improper payment, issues abound. From mistakes in billing amounts to recipient mix-ups to instances of outright fraud, Recovery Audit Contractors (RACs) have seen everything. In the end, these counterfeit claims hurt the greater Medicare system. In fact, research suggests that patients stand to lose 12% of what’s covered today over the next decade. If the CMS is unable to effectively audit fraudulent facilities, there’s no way to recover those essential funds, which are already limited. The idea of exemption may seem attractive, but over time, honest LTCs and SNFs will surely suffer. Even if your operation processes few Medicare claims, it’s always smart to perform periodic internal checkups. Evaluate instances of accuracy and error, and determine best practices that will provide patients the greater quality care they desire and deserve.

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