What is a Medical Home?

© Maigi | Dreamstime.comThe Medical Home, also called the Patient-Centered Medical Home, and the Personal Medical Home, is a movement to solve the problem of fragmented care (one hand doesn’t know what the other is doing) by having a primary care physician or practitioner act as the center of all care information for the patient.   Fragmented care is dangerous (lack of coordination of care causes mistakes and mistreatments), costly (repetition of diagnostic tests and regimens), and wasteful of healthcare resources.  The Medical Home plan goals are to provide care for all individuals, improve care, and decrease healthcare costs.

Crossing the Quality Chasm: A New Health System for the 21st Century” was published in 2001 by the Institute of Medicine.  In this landmark book, the patient’s role and responsibility for navigating the healthcare system and acting as the information hub around which the spokes of primary, specialty and tertiary care providers revolve was denounced as unreasonable and detrimental.  Since 2001 the concept of the Medical Home, a focal point through which all patients receive acute, chronic and preventive medical services, has been the object of a number of pilot projects, most notably the CIGNA/Dartmouth-Hitchcock pilot project announced last summer, a Blue Cross Blue Shield of Michigan project announced yesterday and the CMS Demonstration Projects.  To access more information on the CMS Medical Home demonstration projects, including an email notification signup, click here.

On April 14, 2009, new White House Health Reform Director Nancy-Ann DeParle stated “There are very robust demonstrations of (the medical home) going on right now in the private sector.  Some insurance companies are doing this already, and they have shown real promise. We hope to move forward with (the program) in Medicare.”  DeParle also said  “We want to move toward things that will bend the (cost) curve to create better incentives for physicians and hospitals to treat patients in a smarter way.”

An exerpt from Wikipedia describes the seven characteristics of the Patient-Centered Medical Home, as determined by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association in 2007:

  • Personal Relationship: Each Patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
  • Team Approach: The Personal Physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing patient care.
  • Comprehensive: The personal physician is responsible for providing for all the patient’s health care needs at all stages of life or taking responsibility for appropriately arranging care with other qualified professionals.
  • Coordination: Care is coordinated and integrated across all domains of the health care system, facilitated by registries, information technology, health information exchange and other means to assure that patienst get the indicated care when and where they want it.
  • Quality and Safety: Quality and Safety are hallmarks of the medical home. This includes using electronic medical records and technology to provide decision-support for evidence-based treatment and patient and physician involvement in continuous quality improvement.
  • Expanded Access: Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, physicians, and practice staff.
  • Added Value: Payment that appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home.



What Health Care Providers Need To Know About Medicare and the RAC

Carla Hannibal

By Carla Hannibal, CMM,CPM,CIMBS

Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act.  Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond.  RACs will audit every United States and Peurto Rico health care provider who files with Medicare.  The audit and recovery plan is expected to be in place by 2010 in all 50 states and Puerto Rico on a permanent basis. Based on findings, if compliance with Medicare billing rules is not up to standard, penalties may be assessed including fines and in severe cases, the loss of Medicare billing privileges.

What should providers do?
Health care providers would be wise to ensure their offices are in compliance because Medicare will not provide any specific guidance to the physician or provider of care outside of basic written guidelines.  RAC contracts fees are contingency-based which means they will have every incentive to find errors.  It should be noted that each RAC’s contingency fee is established during contract negotiations with CMS and varies for each RAC.

Region A: 12.45%
Region B: 12.50%
Region C: 9.00%
Region D: 9.49%

For practices, internal changes need to be established to monitor documentation and coding for compliance as well as establishing a framework to track RAC requests.  These are not new requirements to providers.  The provider application and contract clearly states that it is the sole responsibility of the Physician to follow all documentation rules and regulations, coding and billing rules 100% of the time.  Offices setting up compliance guidelines should appoint someone who will be responsible for monitoring compliance within the practice.

Is there a limit to what records RACs will audit?

Yes there is a medical records limit, established by NPI, of records the RAC will audit.

Ӣ Solo Practitioner
Limit = 10 medical records/45 days

Ӣ Partnership of 2-5 individuals
Limit = 20 medical records/45 days

Ӣ Group of 6-15 individuals
Limit = 30 medical records/45 days

Ӣ Large Group (16+ individuals)
Limit = 50 medical records/45 days

What are the RACs focusing on?

Under the program, RACs will focus on CMS-established payment criteria and will consist of both automated claims history reviews from the CMS database as well as complex clinical reviews of patient medical records.   Specific areas of concentration include “not medically necessary services” (or those not meeting the established CMS clinical payment criteria), non-covered services, incorrectly coded claims, duplicate services and incorrect payment amounts.

What is involved in the RAC claims audit process?

The Process consists of six phases.

I.     Data Screening & Claim Selection

II.    Medical Record Request

III.  Record Review and Status Determination

IV.  Post Review Notification

V.    Overpayment Recoupment

VI.   Post Determination- Other Provider Options and Data Tracking

Does the RAC program cover Medicare Replacement policies?

No the RAC program does not detect or correct payments for Medicare Advantage or the Medicare prescription drug benefit.

What happens after a RAC audit?

In those cases of overpayments, the physicians may choose to send a rebuttal of the findings directly to the RAC within 15 days of receiving the RAC’s letter identifying an overpayment.  However this does not stop the clock on the 120-day time period during which you can request a redetermination (first level appeal) from your Medicare contractor or on the interest accrued when money is not refunded to CMS within 30 days of request.  If the RAC discovers that an underpayment has been made to the provider then the RAC will inform the carrier or intermediary who will proceed with the claim adjustment and payment to the provider.

When does all this begin?

Implementation will take place on a rolling basis in 3 phases which began 10/1/08.  The schedule for the program rollout can be found here.


Will your practice be ready?


Carla Hannibal, CMM, CPM, CIMBS is President of Hannibal Professional Services, LLC (HPS).  HPS is a practice management company that provides services for small to medium-sized physician groups.  Carla is a writer, speaker, trainer and highly skilled manager with 27 years of clinical and administrative experience in the healthcare industry.  Her experience in the healthcare industry ranges from claims processing to practice management.  If you need more information on RAC, or help in implementing a compliance process in your practice, Carla can be reached at 623- 204-8992.