×

Warning

JUser: :_load: Unable to load user with ID: 66

logo Print this page
Updated on: June 22, 2012

Connolly Posts 30 DRG Validation Issues

By
Original story posted on: March 22, 2010

ernie

More High Volume, High Dollar Value DRGs

 

The Region C RAC, Connolly Healthcare, posted 25 new DRG Validation Issues to their list of CMS-Approved audit issues, on Tuesday, March 16 plus another five (5) on Friday, March 19. Once again, Connolly has been approved for even more MS-DRGs with high Relative Weights (which equates to high dollar reimbursements) and high discharge volumes (which equates to large number of claims to potentially audit).

 

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 - ernie@edutrax.net

This email address is being protected from spambots. You need JavaScript enabled to view it.

Latest from

Copyright © 2018 | ICD10monitor.com, a division of Panacea Healthcare Solutions, Inc.
287 East 6th Street | Suite 400 | St. Paul, MN | 55101 • TOLL FREE: 800.252.1578