The system, which was mandated in the Small Business Jobs Act of 2010 (SBJA), is designed to detect and flag potentially fraudulent claims in real time. Claims are streamed through the predictive modeling technology as they are submitted. Based on the data in the claims, the system builds profiles of providers, networks, billing patterns and beneficiary utilization. Based on these profiles, CMS can create estimates of fraud and flag potentially fraudulent claims. Though the predictive modeling system is designed to identify potential fraud, claims are not being denied exclusively based on alerts generated by the system at this time.

On Oct 5 the Department of Health & Human Services (HHS) Office of Inspector General (OIG) announced the publication of the Fiscal Year 2012 HHS OIG Work Plan. The work plan, which can be downloaded for review in its entirety on the OIG website, outlines the items to be addressed by the OIG in the next fiscal year. The 2011 OIG Work Plan highlighted a number of sleep-related projects for the OIG and sleep continues to be an important topic in the 2012 Work Plan.

In a previous announcement about eRx hardship exemptions, the AASM reported that the Sept. 6 Federal Register included a final rule describing changes to the eRx Incentive Program.  Beginning in 2012, providers who do not successfully prescribe electronically per Centers for Medicare & Medicaid Services (CMS) requirements will receive a penalty of -1 percent of allowable changes.  The final rule outlined six exemption categories for providers who are unable to successfully participate in the eRx program due to hardship. The request submission deadline is Nov. 1.

The Medicaid Recovery Audit Contractor (RAC) program is projected by the U.S. Department of Health and Human Services (HHS) to save $2.1 billion over the next five years by detecting and correcting improper payments by reviewing claims after the payments have been made. The program is based on the existing Medicare Recovery Audit program and will be largely self-funded. The final rule for the Medicaid RAC program goes into effect on January 1, 2012.

The Centers for Medicare & Medicaid Services (CMS) has directed contractors to use postcards announcing the open participation enrollment period this year in place of the CD packets. Previously, the CD packets included an electronic copy of the Medicare Physician Fee Schedule (MPFS). Due to the frequency of last-minute changes to the MPFS in recent years, CMS has directed contractors not to distribute electronic copies. Instead, contractors will keep updated copies of the MPFS and enrollment information on their websites, which will be listed on the postcard. Participating health-care professionals who do not wish to change their participation status will not be required to take any action during the open enrollment period. Postcard announcements will be mailed in early November.

In January, the AASM announced that the Centers for Medicare & Medicaid Services (CMS) approved the establishment of a physician specialty code for sleep medicine. The original approval letter from CMS indicated that the code would be established after October 2011. In an email received Thursday September 8, staff from the CMS Provider Enrollment Operations Group notified the AASM that the establishment of the specialty code has been delayed. CMS staff cited system implementation issues, which will prevent the code from being established until April 2012. The AASM will continue to keep members updated regarding this important issue via the Weekly Update. Once the specialty code has been established, members will be provided information about how to change their specialty information with CMS.

In the Sept. 6 Federal Register, the Centers for Medicare and Medicaid Services (CSM) published a final rule describing changes to the eRx Incentive Program. Beginning in 2012, providers who do not successfully prescribe electronically per CMS requirements will receive a penalty, also known as a payment adjustment, of -1 percent of allowable charges. This adjustment is projected to increase to -1.5 percent in 2013 and -2 percent in 2014.

Providers who believe they cannot meet the requirements of the eRx incentive program due to hardship can apply for exemption from the eRx program. Major changes to the eRx program, as outlined in the final rule, include the addition of new hardship exemption categories as well as an extension of the deadline to submit a hardship exemption request. The exemption deadline is now Nov. 1, 2011.