by Sean M. Weiss, VP and Chief Compliance Officer at DoctorsManagement
June 17th, 2016
More and more I am receiving calls from clients and their attorneys from around the country asking what these CBRs mean and whether they should be concerned. The answer is simple: any time a payor or one of their contracted "Bounty Hunters" sends you a letter stating you're an outlier compared to your peers, you better sit up and pay attention. I also hear people say, "Who cares? If your documentation supports the billing of the services, let them audit you!" While there may be some truth to that statement, YOU should care about being audited because it costs money, creates morale issues, generates tension and launches an overall distraction for the organization.
If you have not heard of CBRs, you need to pay attention because it is only a matter of time before your organization gets one, or two, or ten... "A Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider. CBR's contain actual data-driven tables and graphs with an explanation of findings that compare the provider's billing and payment patterns to those of their peers on both a national and state level. Graphic presentations contained in these reports help to communicate a provider's billing pattern more clearly. CBR study topic(s) are selected because they are prone to improper payments." GlobalTech (http://www.cbrinfo.net) is the company providing this service for the Centers for Medicare and Medicaid Services (CMS) and they define CBRs as follows: "Comparative Billing Reports (CBRs) are educational tools administered by the Centers for Medicare & Medicaid Services (CMS). They are developed and disseminated under contract by eGlobalTech, a woman-owned Federal services firm based in Arlington, VA.
The CBRs are disseminated to the provider community to provide insight into billing trends across regions and policy groups. A/B MACs have been producing and disseminating limited numbers of CBRs to targeted providers for many years. CMS has now formalized and expanded the program to a national level. The program also includes a CBR Support Help Desk that providers can contact to ask questions regarding the CBRs. Following the release of each CBR, eGT will hold an educational teleconference or webinar to educate providers on the substance of the CBR and to provide an opportunity for the provider to ask questions.
The CBR is just one tool that CMS uses in its ongoing efforts to protect the integrity of the Medicare Trust Fund. Other efforts include:
Educating providers about Medicare's coverage, coding and billing rules;
Reviewing claims before they are paid to ensure compliance with coverage, coding, and billing rules (called prepayment review); and
Reviewing claims after they are paid (called postpayment review) to identify and collect overpayments made to providers.
CMS employs A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment (DME) MACs to enroll providers and suppliers into the Medicare program, process claims and bills, educate providers, conduct prepayment review, conduct postpayment review, and perform othertasks in accordance with the specific contract. CMS employs Recovery Audit Contractors (RACs) to perform postpayment review. CMS also learns of improper payment vulnerabilities through reports issued by the Department of Health and Human Services (HHS), Office of the Inspector General (OIG) and the Government Accountability Office (GAO) and data analysis conducted by CMS employees."
While I provided you a lot of information regarding CBRs straight from the horse's mouth, what you need to realize is that CBRs lead to audits. CBRs, in this compliance professional's opinion, are tools of intimidation to force providers who may be doing everything correctly to change how they are doing things, ultimately resulting in lower reimbursements, saving the payors money in the long run.
We have been in a state of perpetual targeting at the highest level by payors and private payers for more than a decade and it is not going to ease up. Recently, we have had more than a half dozen health care organizations and law firms reach out to us regarding CBRs their clients have received within the past few months only to be the focus of a Probe Audit or placed on pre- payment review. Both of these are devastating to a medical practice, but being placed on to a pre-payment review changes the entire look and feel of an organization and can put smaller practices so far behind the "8-ball" their only option is to shut down or sell. The only way to ensure you're ready for what is coming down the pike is to be aware and DoctorsManagement, with our comprehensive compliance solution - Compliance Risk Analyzer (CRA) and The Department of Audit and Regulatory Compliance (ARC) and Audit Solutions, we can protect our clients and help you to understand your risks based on advanced mathematics, predictive modeling and the industry's most comprehensive audits and education services. Additionally, we provide post-audit extrapolation, expert witness services for Administrative Law Judge (ALJ) and Federal Case Reviews.