By now, many if not most hospitals nationwide have begun to receive RAC requests based on the approved issues posted on their Web sites. All four RACs have been approved for issues related to MS-DRG validation and coding accuracy, and it is important to remember that:

"DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record."

Now the obvious understanding here is that, although the request for services is made to the hospital provider, the attending physician is intimately involved in the request. What appears to be missing is the connection to the physician services delivered and assumedly billed for these hospital services. The focus would appear to be on the hospital bills, which of course are more substantial.

This connection (or lack thereof) has been discussed in previous RAC Monitor articles, including one that outlined a conversation held last summer with CMS Commander Casey, but it is not the subject of this article. However, I do want to address something similar.

False Sense of Security

Let's consider these two questions:

1. Should physicians get a sense of "comfort" from this apparent focus on hospitals; and

2. Have the RACs already posted any issues by which physicians will be impacted?

The answer to the first question is "no," because CMS has made it quite clear that all providers that provide and bill for services to Medicare beneficiaries are subject to review by RACs. Plus, the RACs haven't really forgotten about you, which leads us to our next answer.

The answer to the second question is a resounding "YES - physicians are already under review," because the RACs already have been approved for issues affecting Part B providers. And those issues, incidentally, are not exactly small potatoes.

What's at Risk?

Physicians should be paying close attention to the posted RAC issues, as some already may have begun to receive RAC denials. Also, physicians should consider that their relationships with their facilities may be at risk if those facilities start receiving denials based on incomplete or insufficient physician documentation. Remember, the hospitals are being denied and are the ones losing the money, but it is CMS, and more specifically the RACs, that are making those decisions - not the hospitals.

But what about issues that directly affect the physician and his/her revenue? What issues should physicians be examining to see how they might fare against RAC review?

The RACs already have been approved to review, audit and subsequently deny claims related to hydration services, chemotherapy, NCCI edits, MUE's (Medically Unlikely Edits), the technical component of radiology services and "new patient" visits. Let's look at lists of these issues compiled by the two most active RACs, Connolly Healthcare and Health Data Insights (HDI).

Part B Issues Already Approved for RAC Review

Here's the list of Part B issues posted by Connolly Healthcare, the RAC for Region C, through February: