Overpayments for Medicare fee-for-service claims reported by the federal government in 2007 totaled $9.8 billiion, with $4.3 billion attributed to overpayment of inpatient claims. The Centers for Medicare & Medicaid Services (CMS) uses education, special studies, fraud investigation, and medical record review by Medicare claims processing contractors to protect and recoup Medicare assets. With the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress added another effort to protect Medicare funds: Recovery Audit Contractors (RAC).
FMQAI has helped hospitals reduce unnecessary Medicare admissions with the Case Management Assignment Protocol (CMAP) since 2003. Hospital staffs use the protocol to assign patients to the correct billing category-inpatient vs. observation. CMAP addresses high denial areas such as symptom DRGs, emergency departments admissions, and short stays. Hospitals with a strong commitment to using the protocol have been shown to reduce inappropriate inpatient admissions by 91%.
