The Geek Factor – Do Your Own Data “Mining” on the Contractors’ Web sites

nbeckleyBy Nancy J. Beckley, MS, MBA, CHC


It seems like we've been in the starting blocks for months. Well, actually, we have in the starting blocks for months. Every so often it looks like we might be ready to take our marks, but the whistle blows and we all stand up again. We're anxious to start the RAC race, and we keep trying to get ready; problem is the same information appears to be re-circulating again and again.

So last night I dreamed I was a Rock RAC star. I guess I am a geek of sorts. I developed my first database on an Apple IIe computer, in a program called Apple Works, and my first spreadsheet of an analysis of spinal cord injury admissions was done on the same computer using VisiCalc (long before Lotus and Excel). I really like to look at data and analyze data different ways (I aced three graduate statistics courses -- please don't ask about microeconomics).

What If...

If I was a RAC auditor, what type of data should I be looking at? Somebody has to tell the geeks in the backroom how to write the programs, and what to look for. So where are the RAC stars looking for this information so they can accommodate the programming geeks?

First of all, the demonstration program, although initially only in three states, was enough of an eye-opening financial experience for Congress that it moved forward with the full rollout of the permanent program. Even hundreds of millions of dollars in paybacks still sounds good in our trillion-dollar economy. The reports are fairly clear on the findings and the fat paybacks, and continue to be updated as more appeals make their way through that process. Cheryl Servais' article "Likely RAC Targets Revealed" (http://www.racmonitor.com/news/archives/78-likely-rac-targets-revealed.html) has become one of the most well read articles on RACMonitor.com and is an excellent place to start building your database of known areas where improper payments have been found. Assume that the RACs have incorporated all these findings moving forward, having added to them and tweaked them.

The RACs don't really have to spend a lot of time thinking up new issues when there are so many published issues lying in wait for another run through the newly geeked-up propriety software. Let's take a look at a few, and how you can go about conducting your own investigation of these sources and adding them to your database of potential problems.

Cert Reports

The CERT (Comprehensive Error Rate Testing Program) issues reports on paid claim error rates of the carriers, fiscal intermediaries and MACs. The latest full report, published on the CMS Web site in May 2008, contains information on improper payments on claims for which medical documentation was reviewed.  (The CERT reports can be accessed at: https://www.cms.hhs.gov/apps/er_report/index.asp)  What often is more revealing, however, is the data that the CERT contractor provides back to the Medicare contractors on their individual error rates. First Coast Services Options, the MAC in Florida, recently addressed a high error rate regarding documentation supporting therapy codes billed by Part A outpatient providers by hosting a webinar to address these coding and documentation issues.

Highmark Medicare Services has detailed its CERT information on a Web page devoted to the CERT program. The most recent report covers the April - June record of the most common CERT errors for HIGHMARK paid claims. There are Part A reports as well as Part B reports. Two-thirds of the Part A errors, for example, occurred due to the fact that laboratory and/or diagnostic service records did not contain a physician's order or valid requisition form in the documentation. In order to identify this as a paid claim "error," the medical record was reviewed by Advance Med (the CERT contractor). Sounds like a good topic for a RAC, doesn't it? And it actually doesn't require much reading of the medical record - just a quick look to see if the order was present, meaning no eye strain on the part of the reviewer trying to determine medical necessity (almost like shooting fish in a barrel). On the Part B side, 43 percent of errors occurred due to insufficient documentation -- mostly from physical therapy having missing or illegible signatures -- and another 43 percent was due to medical necessity errors involving physicians' orders on lab or diagnostic tests.

I think you must be getting the drift; there should be enough of this low-lying fruit that will get CMS approval as a RAC topic. Visit the Highmark CERT Web page here: http://www.highmarkmedicareservices.com/cert/index.html

Highmark also publishes a monthly list of "Top Ten Claims Submission Errors", and the June report has just been posted. This is another potential data-mining topic for the RACs.

Trailblazer also has devoted a page on its Web site to the CERT program, and although its reports do not offer the insightful analysis of Highmark's, they nonetheless offer a glimpse into the types of errors that are being caught by the CERT contractor. Visit the Trailblazer CERT page here:  http://www.trailblazerhealth.com/Education/Comprehensive%20Error%20Rate%20Testing/Default.aspx?DomainID=1

Other Medicare Contractors

Take a proactive step and look at the other Medicare contractors in your region - assume that the RAC contractor will be reviewing CERT results, the results of published probe reviews and other related sources in which billing, coding and documentation error have been identified. Go to each of the contractor's Web sites and sign up for e-mail updates: you should be reading them, because the RAC folks will be. Don't leave yourself in the dark.

In summary, CMS instituted the RAC program as another method of detecting improper Medicare payments. The hitch on this program is that the RAC contractors get a bounty. It has been publicized widely that each RAC will utilize propriety software and data analysis systems to look for these improper payments.

Technology alone will reap rewards for finding coding errors and other items that can be determined as improper simply by running claims against the decision tress in their software. The second method will require medical review to determine if an improper payment was made. Prior to reviewing these medical records the topic must be posted to the RAC Web sites in each respective RAC region.

Expect the RACs to snatch their review topics from publicly available information found on the various contractors' Web sites. If you're really adventuresome, take the Trailblazer webinar on the CERT program scheduled for this October.

I'm sure you'll get some good ideas!

Sweet Dreams!

About the Author

Nancy Beckley is a co-founder and President of Bloomingdale Consulting Group, Inc., providing consulting services to the rehab professional.  Nancy is certified in Healthcare Compliance by the Healthcare Compliance Board, and serves on the Part A and Part B Provider Outreach Education and Advisory Panel for First Coast Services Options (Florida Medicare).  She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities

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