Four (4) of the newly approved issues are for MSDRGs with Relative Weights of better than 5.0. Also, seven (7) of the 25 new issues are ranked (by number of discharges in FY09) in the top 100 DRGs nationwide. Connolly and the rest of the RACs are not allowed to choose their audit issues simply by virtue of a high reimbursement value, nor can they choose them by random selection. The RAC Statement of Work (SOW) is clear on this issue: the RAC must garner approval from CMS before they can begin widespread review of an issue. To earn that approval, they must present compelling evidence to CMS that suggests improper payments have been made, and that audits of those issues might return significant dollars to Medicare.
Nevertheless, this latest round of approval/postings seems to continue a pattern previously noted in Connolly's February postings, and reported here on RAC Monitor and on Medical Coding Journal. Such approvals might suggest that Connolly is certainly able to gather sufficient evidence to pursue fairly large volumes of claims, as well as many of the highest paying DRGs.
If the rationale listed by Connolly in a recent Additional Documentation Request Letter (ADR) sent to a Georgia hospital is any indication, it would appear that Connolly has been able to make good use of evidence gathered during the RAC Demonstration. See a copy of the letter and our analysis of it here.
Virginia and West Virginia are still noteably absent from the list of states where Connolly is approved to review these issues. The 13 states affected by the new approved issues are: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas.
The Additions to Connolly's Approved Issues List
Below are the newly posted and approved audit issues for RAC Region C. For your convenience, we have added some data not found on the RAC pages: each DRG's Relative Weight taken from the CMS documents, which can be found here.)
The list shown here has been sorted by Relative Weight, highest to lowest:
To see the complete original listings (on the RAC websites), visit this page.
Or, to find a more useful listing of all the RACs' posted issues, visit this page on eduTrax®. (Registration required.)
Still No Medical Necessity Reviews
All of the above approved issues still include this caveat:
(At this time, Medical Necessity excluded from review).
We again remind everyone that Medical Necessity Reviews could be approved by CMS any day now, since the CMS RAC Review Phase-In Strategy allows for such audits to begin sometime in calendar 2010.
Stay tuned, as the situation unfolds.
About the Author
Ernie de los Santos is the chief information officer at eduTrax®. He joined the company at its inception and has been responsible for the creation, development and maintenance of the eduTrax® portals - a set of Web site devoted to providing knowledge, resources and compliance aids for U.S. healthcare professionals who are involved in revenue cycle management.
Contact the Author - firstname.lastname@example.org