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As reported on www.RACmonitor.com, by the third quarter of 2011, Recovery Auditors (RAs) were behind in terms of projected recoupments from providers and were relying heavily on automated reviews. With these shortfalls and the fact that automated reviews recoup about a tenth of what complex reviews recoup, the Centers for Medicare & Medicaid Services (CMS), from its perspective, had a problem.

On Sept. 1, 2011, the new statement of work (SOW) was released,[1] putting a far more aggressive workload, including quotas and CMS oversight, on RAs. The new SOW also included cross-referrals between CMS and contracting entities. Consequently, the RAs made up ground in the fourth quarter of 2011 and ended the fiscal year with $939.3 million in corrected billing – an average of $235 million per quarter. This momentum has not slowed during the current fiscal year, with $422.7 million corrected in the first quarter and $649.9 million corrected in the second.[2] This is due in large part to the fact that the RAs dramatically shifted their focus to complex reviews. The new SOW also clarified that all providers will be affected by this, not just hospitals, and that RAs are being instructed to report potential fraud. With the Medicare Administrative Contractors (MACs) in place, CMS can view a patient’s entire episode of care across providers, including physicians.

The point is, RAs and other billing auditors are not going away – they are growing. A sure indicator is the article from last month in which Greg Calosso reported on congressional and U.S. Government Accountability Office (GAO) efforts to ensure coordination among CMS audits. As the audits expand and affect providers’ margins and staff workloads, members of Congress are hearing from their provider constituents.

What to Do?

The American Hospital Association’s RACTrac results indicate that, for the 2,220 hospitals reporting, only about 30 percent of RA denials are appealed. We know the only way to win an appeal is by assigning the appropriate level of care for the patient and appropriately documenting to support that level of care – this is true of all CMS billing audits. Only a strong, coordinated system of compliance will safeguard a provider on all fronts and provide strong evidence when appealing.

We cannot emphasize the multi-disciplinary team effort required to build and maintain a compliant billing system enough. In speaking with colleagues and providers, I have noted a consistent theme: at many facilities, an RA coordinator and the revenue cycle team, without additional resources and support, are solely responsible for responding to audits and recoupments. Concurrently, we hear that RA coordinators cannot keep up with record requests and tracking of deadlines. Additionally, hospitals are acquiring physician practices, and, depending on how the contracts are developed, those hospitals are inheriting the physicians’ RA risks – and the related audit duties again are falling primarily to the RA coordinator and the revenue cycle team.

Providers need to turn this into a “team sport” with a coordinated committee structure in order to properly address the teams that make up the long list of auditors.

Providers who have been successful in building a strong offensive team to deal with audits and compliance not only have defended against recoupments and takebacks, but they have reduced the number of audits they are facing by becoming a less inviting target.

Forming the Team

Start with a RA committee that is a permanent part of your quality committee structure; while we call this an RA committee, it should serve as the billing compliance committee. As performance improvement teams go, the RA committee should serve as the hub of knowledge for billing audits, ensuring a global perspective on risk and vulnerability. Typically, the director or vice president of care coordination heads this committee, with the HIM director serving as vice chair. Your physician advisor or chief medical officer also is vital to the success of this committee, along with strong C-suite support. This is where a strong RA coordinator under the direction of the committee is extremely effective.

Then set external and internal benchmarks for compliance improvement. The AHA RACTrac is an excellent source for external information. (Go online to http://www.aha.org/advocacy-issues/rac/ractrac.shtml for more information.) The latest results from RACTrac show that one- and two-day stays are the main focus for inpatient reviews. In the outpatient setting, coding is the top reason for takebacks accomplished via automated review. For internal benchmarks, use reports from your RAC/audit-tracking tool to look for a trend highlighting where your recoupments have occurred or identifying a pattern in record requests. Is the issue in cardiology, or another high-volume service in your hospital?

Once you determine where you are vulnerable, create a multi-disciplinary chart audit team to find the root cause of your billing denials. Just like the RA committee, the chart audit team should be a permanent fixture and expand into open chart reviews to be proactive in terms of ensuring the existence of appropriate documentation.

While the average hospital has been playing defense, and losing, we see that successful hospitals have been playing offense, winning 77 percent of appeals.[3]

As the old sports saying goes, sometimes the best defense is a good offense.

Setting up the Offensive Line

In football we see three main positions – the center, tackle and guard – making up the offensive line. For audits we also have three main positions: the admission care manager (ADC), the clinical documentation improvement specialist (CDIS) and the physician advisor (PA). The ADCs review every patient for appropriate bed status and advise physicians; the CDIS reviews concurrent documentation and coordinates with physicians and clinicians on appropriate documentation; the PA provides advice and second-level medical necessity reviews with medical staff. If everything goes smoothly, your medical staff will depend on these individuals for advice like a quarterback reads a blitz. The back-end coding and billing will reflect the level of care. In fact, you may find yourself collecting more reimbursement thanks to more accurate coding – and  maybe throwing a few more touchdowns per game.


 

About the Authors

Elizabeth Lambin, MHA, is a partner in PACE Healthcare Consulting. Elizabeth has more than 20 years of C-suite level hospital executive management experience.  Most recently, she was the CEO/Market President for Tenet Healthcare’s Hilton Head Regional Healthcare. Elizabeth holds an undergraduate degree in Business Administration, Cum Laude and a Master’s in Healthcare Administration from the University of South Carolina.

Gregory Calosso is a senior consultant for PACE Healthcare Consulting. Greg joined PACE in 2011 after receiving his Masters degree in health administration from the Sloan Program in Health Administration at Cornell University. His past experiences include working in hospital planning and business development, organizational leadership consulting, and clinical research. He holds an undergraduate degree from Cornell University’s Division of Nutritional Sciences.

Contact the Authors

Elizabeth.Lamkin@pacehcc.com

gcalosso@pacehcc.com

To comment on this article please go to editor@racmonitor.com


[1] “Statement of Work for the Recovery Audit Program.” CMS RAC website, URL: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/090111RACFinSOW.pdf. Accessed July 30, 2012.

[2] “Medicare Fee-for-Service Recovery Audit Program May 2012.” CMS RAC website, URL: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed July 30, 2012.

[3] “Exploring the Impact of the RAC Program on Hospitals Nationwide: Results of the AHA RACTrac Survey, 1st Quarter 2012.” May 10, 2012.  May soon be available on the AHA RACTrac website: http://www.aha.org/advocacy-issues/rac/ractrac.shtml.

Sending Records to Auditors: Taking Paper Out of the Submission Process

Responding to audits can be time-consuming and costly, and if not managed properly, they can pose a significant financial threat. Although many of you have an audit workflow process and system in place to respond to auditor requests, there are still challenges ahead – and more audits to come.

The success of the Medicare RAC program not only has caused its expansion, but it has emboldened other payers to follow suit. Additional audits have arisen from MACs, CERT, ZPICs and the OIG. Medicaid also is following in the steps of Medicare and now has a Medicaid RAC program of its own. And the three-year pilot of Medicare pre-payment reviews just now is getting underway in 11 states.

Case limits are being modified. For example, RACs now can request up to 20-30 percent more records in a 45-day period, depending on the size of your institution. There is even an effort being made to extend the lookback period from three years to seven years. 

This increased audit activity is prompting institutions to increase staff and driving up the expense of managing audits – as more audits are surfacing, after all, more revenue is at risk, forcing you to spend more in your quest to hang on to that revenue. All of this leads to the point of this article. 

Audit management is an ongoing activity and not a “one-and-done” effort. The process needs to be reviewed and refined, with adjustments made for each new audit. Toward that end, let me review the eight key action steps necessary to ensure that each and every audit request is managed properly.

Step One: Educate Key Stakeholders

First, you must identify these key stakeholders, and second, you need to provide them with access to historical information specific to the type of audit so they can better understand the potential revenue impact. Third, they need to understand the differences among the federal and state regulations governing each type of audit. Lastly, this education needs to be ongoing.

Step Two: Create a Team and Meet Regularly

The team must be multi-disciplinary. Audits affect many different areas of a hospital, and diverse expertise is needed to manage record requests and appeals processes. This team may need to be on call full-time and must be accountable, understand the audit workflow and adhere to timelines/deadlines. Missteps related to deadlines can cause technical denials.

Step Three:  Tracking

It is not reasonable to track audit activity manually, using spreadsheets. The variation and volume of audits require tracking technology. Best practices suggest using tested software that tracks and trends information; automating the “tickler” function to ensure timely responses is a key feature of this software. The software also needs to be instinctive and needs to allow you to look for negative patterns that can be corrected to prevent future recoupment.

Step Four: Request Letter Management

Proper management of request letters is vital to audit management. A workflow must be in place that allows you to engage the release of information activity quickly. An ill-defined process can cause delays leading to denial and recoupment of revenues, warranted or not.

Step Five: Decision Letter Management

Decision letters must be reviewed and processed quickly. Ensure that the letter is attached to matching records in a file that is complete and easily accessible. If you decide to appeal the results of the decision letter, easy access to the complete file significantly reduces response times.

Step 6: Appeals Management Process

Appeals must be tracked meticulously in order to ensure that deadlines are not missed. Concurrent appeals are inevitable, and a process must be put in place to track and manage multiple requests for due dates and storage. Automated reminders and emails to trigger action are recommended.

Step 7: Establish Real-Time Financial Management and a Dashboard Review Process

Tracking dollars at risk is key to understanding the potential impact on your revenue. Invest in a tool that is easy to manage and will provide real-time reports. It should have a dashboard view of dollars at risk as well as dollars won and lost. You also should be able to easily trend all this information.

Step 8: Establish a Process to Prevent Denials from Recurring

Conduct your own internal audits and track/review the results regularly. Use the internally generated data to validate that any and all vulnerabilities are identified and fixed. A major to-do task is to work with clinical documentation experts to improve your documentation. Physicians are the drivers of your revenue; they are also crucial to your ability to hold on to that revenue in that they must properly document and show medical necessity. Physicians need to be part of the audit workflow.

Audits constitute a growing challenge and can pose a real threat to your revenue. Additionally, pre-payment reviews will involve audits before you even receive that revenue. Using the above eight-step process as a guide, coupled with funding and using trusted technology, will provide consistent reporting and facilitate your audit workflow. Follow these steps for optimal audit success!

About the Author

Lori Brocato, HealthPort Audit Product Manager, has over 16 years of experience in the healthcare technology industry creating product lifecycle plans and executing product strategies. Ms. Brocato frequently serves as an audit expert sharing audit management trends and best practice guidelines as a regular presenter for industry events and webinars.  She is the author of HealthPort's audit Insights Blog and provides expert input for many trade publication articles each year. Ms.Brocato holds the distinction of being RAC-certified by the Medicare RAC Summit and is a member HIMSS, HFMA, and AHIMA.

Contact the Author

Lori.Brocato@healthport.com

To comment on this article please go to editor@racmonitor.com

alert-powered-by-decision-health

You know to be aware of disgruntled employees who can turn into whistleblowers, but be ready for another type of watchdog looking for fraud: Senior Medicare Patrol (SMP) members and Medicare beneficiaries.

In 2011, SMP had a 14-percent increase in the number of volunteers over the year before, bringing the total to almost 5,700, according to a June HHS Office of Inspector General (OIG) report. The SMP saw a 45-percent increase in the number of Medicare beneficiaries who attended group education sessions, from 298,097 in 2010 to 431,128 in 2011.

Some of the SMP efforts have modest financial results – about $19,283 in Medicare funds were recovered in 2011 and cost avoidance totaled $247,850 – but SMP members reported two “large-dollar cases” to contractors. In one case, the Medicare contractor is seeking to recover $2.9 million in overpayments from a provider, the OIG report stated.

Those numbers could grow. The report showed 39 states, the District of Columbia, Guam and the Virgin Islands referred other cases for further action. Georgia referred cases involving more than $4 million for further action, while California, Delaware, Michigan, Nebraska, New Mexico, Texas and Utah referred cases totaling at least $100,000 each.

For more information on the SMP and its results, visit http://oig.hhs.gov/oei/reports/oei-02-12-00190.asp.

2 RAC Issues Approved in May Posted

Recovery auditors (RACs) posted two issues last week that were approved in May. HealthDataInsights, the RAC for Region D, posted an issue about multi-use vial waste for Herceptin. CGI, the RAC for Region B, posted an issue about outpatient Bevacizumab (Avastin) services. See the chart below for more information.

Physician

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Multi-use vial wastage: Herceptin (Trastuzumab)

5/25/12

RAC Region D

Multi-use vials are not subject to payment for discarded amounts of drug or biological. Per the manufacturer label, J9355 Injection, Trastuzumab, 10 mg (Herceptin) is only supplied in a multi-use vial. Providers should only bill the units associated with the dose administered to the patient.

CMS Pub. 100-02 chapter 15; CMS Pub. 100-04 chapter 17; Herceptin approved package insert 1-18-2008, FDA website; CDC safe practices for medical injections FAQs; questions about multi-dose vials

Outpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Outpatient Bevacizumab (Avastin) services

5/25/12

RAC Region B

Bevacizumab (Avastin) represents 10 mg per unit and should be billed one unit for every 10 mg per patient. Claims for J0150 should be submitted so that the billed units represent the administered units, not the total number of milligrams.

CMS Change Request 5718 dated Sept. 14, 2007; OIG report A-09-10-02019; NGS article about Avastin related to LCD 25820 (A46095)

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

EDITOR'S NOTE: This is the last article of a two-part series on the algorithms of medical necessity.

 

As compliance professionals, the conversation about qualifying medical necessity or medical decision-making probably has surfaced at one time or another during education with providers, coders or auditors.  As discussed in the first article of this two-part series, these phrases often  are used interchangeably and have caused all of us to think about how to best manage and monitor when it comes to documentation and coding.

 

Active Communication

 

To start the process of managing medical decision-making among physicians and auditors (or coders), communication is a key component that many organizations have failed to recognize.  As hospitals and health systems transition through business models to employ providers, the dynamics of the central billing office (CBO) have become indispensible as they pertain to facilitating the consolidation of billing, coding and auditing staffs. As a part of this model, personnel sometimes are moved to a different location, where they may not have the luxury of direct communication with their providers. Furthermore, CBO models also may have their own chains of command to provide feedback if errors occur within the revenue cycle. Without this regular correspondence between providers and coders, the notion of one party assuming what the other is thinking (or documenting) may not represent the best support system when appealing a CMS audit.

 

Understand Your Provider Specialty

 

So consider that your compliance department now is scheduling regular meetings with providers. Aside from feedback from educational audits or the input about new coding rules, what can I learn from my physician? Let's go back to the first article and the first part of the medical decision-making algorithm: the number of diagnoses or problems. Remember, within the industry this is a fairly standard template for indicating what type of decision was rendered for a particular office visit.

 

Again, there are four choices, but let's focus on two of them: "self-limiting problem" versus "new problem." This can look very different depending on specialty or sometimes your provider. To better audit or code for your specific provider, take their top 20 diagnoses and have a conversation about how each is managed with regard to history, exam, time and overall ease of treatment.  This process can provide insight that the auditor can use to instruct other staff or providers, and this potentially can bolster one's case in the appeal process for a payer audit.

 

Monitor Performance and EHR Data

 

 

As with almost all compliance processes, if you can't measure it, you can't manage it.  We measure everything when it comes to new and existing processes. Let's redirect the focus back to medical necessity. Consider that the compliance department and providers are communicating regularly and have developed internal tools to understand the process of contrasting diagnoses that are more straightforward to those that are more significant.  The health system recently transitioned from a pure dictation system to a full electronic health record.  The transition team has provided templates and pre-populated areas where providers can click and drop in notes.  Documentation is thought to be more complete than ever. Think again, though: what may be dropping in may not be the intent of what's coming out.

 

For providers, this is truly an "ah ha" moment, and unfortunately, CMS has caught on as well. If you can do two things in the first few months of optimization in terms of electronic health records, do the following: a) turn off the encoder and b) print your finalized notes for your providers to "self-audit" and test note logic. If there is a common glitch in electronic health records, it's the pre-populating of active problems to current assessment.

 

If the provider did not cover the problem in the daily visit, the diagnosis should not be included on the claim form or within the assessment portion of the note. Always advise providers to view notes before authentication is completed to ensure that all information is correct.

 

In the coming months, a new series of articles will focus on electronic health record errors and how to identify them before the government finds them first.

 

About the Author

 

Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.

 

Contact the Author

 

jana.gill@gillcompliance.com

 

To comment on this article please go to editor@racmonitor.com

 

Malnutrition: Documentation for Compliance and Clinical Accuracy

Consider the following scenario: a 72-year-old man with diabetes and coronary heart disease is scheduled for an elective outpatient TURP for symptomatic BPH. He had been cleared for surgery by his internist two weeks earlier, i.e., his physician determined that his condition was stable and his risk of adverse outcomes was acceptably low. When he arrives at the hospital on the morning of surgery, however, his blood pressure in the pre-op suite is 180/98 and his finger-stick blood sugar is 398. The patient says he thought he was supposed to stop taking his medicines immediately before surgery, so he failed to take his two blood pressure medications and insulin the day before. The internist is called, the surgery is canceled and the patient is sent home.

Since June 30, 2011, all Medicare FFS claims are analyzed using predictive modeling before they are paid. Section 4241 of the Small Business Jobs Act of 2010 mandated the Centers for Medicare and Medicaid Services (CMS) implement a predictive analytics system to analyze Medicare claims to detect patterns associated with high risk of fraudulent activity. Based on the analysis, profiles of providers, networks, billing patterns, and beneficiary utilization have been developed. These profiles have been used to create risk scores which are used to alert CMS of aberrant behavior.

 

Home health claims contain a significant amount of information to provide CMS with a picture of the patient's current condition, the services provided, and length of services. The claims include Diagnoses, which should support the medical necessity of the ordered services. The Statement Covers Period (From/Through date) and the Admission Date, which indicate how long each patient has been actively on service, can be used to determine if an agency has a high recertification rate.

 

The HIPPS code submitted on the claim reveals if the episode is an early episode (the first or second episode of home health care without a 60-day break in services) or a late episode (the third or later episode without a 60-day break in services). Claims submitted with a new Admission Date but a late episode indicate the agency is admitting a patient who has already received two episodes of home health care within the past 60 days from another agency or that they are readmitting the patient to their own home health agency within 60 days of discharge. Both of these situations occur in the normal course of home health care, but if they occur frequently could indicate fraudulent behavior.

 

The HIPPS score also includes the clinical, functional, and therapy utilization needs of the patient based on the completed OASIS assessment. Typically this value should correspond with the intensity of services provided. If agencies have a pattern of submitting claims with high therapy utilization and HIPPS scores indicating low clinical and functional needs, it can be indicative of a higher risk of fraudulent activity.

 

However, the claim is only a snapshot and not a detailed portrait; only the complete clinical record can support or reject an assumption of inappropriate billing. Therefore, CMS does not deny claims solely based on the alerts, but uses the data to assist in claims review activity and to enhance its database for future activities.

 

Forms of predictive analysis have been used for decades to manage patients at high risk for hospitalization, falls, etc. Predictive modeling risk adjustments are used to compare outcomes based on OASIS assessments. History has taught agencies to be proactive in approaching the results of the analysis and to develop a plan of action based on the findings.

 

Agencies have taken action based on predictive modeling when developing programs for their patients. Falls and hospitalization prevention programs, resource management plans, disease management programs, and other programs based on the predictive characteristics of the patients they serve have long been a part of home health care. Risk-adjusted outcomes from their OASIS assessments are used to create performance improvement plans to address less-than-optimal outcomes.

 

Now agencies must apply the same approach to the analysis of their claims and the services they provide. They should be aware of their numbers: what is the agency's recertification rate, average number of visits per patient episode, average length of stay, average number of therapy visits per patient episode, and the correlation between diagnoses, functional scores, and visit intensity. Based on these findings, agencies should prioritize their clinical record audits-choose the cases in which the patient has been on service for multiple episodes, been transferred from another agency and/or has high therapy utilization. They must evaluate if the documentation clearly identifies the patient's need for service and supports the skilled need and medical necessity of the services provided as reported in the OASIS assessment.

 

Failure of documentation to do so can usually be traced to one of three occurrences: First, the OASIS was not accurately completed to reflect the patient's true functional needs. This typically occurs when the functional scores are determined by a nurse instead of a therapist. Agencies who identify this problem will need to either retrain the nurses or get more input from the therapists. Second, the documentation is poorly written and does not reflect the true condition of the patient or the skill level of the services provided. Training in proper documentation techniques is the only solution to this problem. Third, there can be a true disconnect between the patient's needs and the services provided. Agencies who identify this problem will need to work on care planning and oversight.

 

CMS believes that ultimately, predictive modeling will benefit honest providers by minimizing the disruption to providers with low risk scores. In most instances, agencies that are aware of the information being provided on their claims and conduct their own internal reviews should not be seriously affected by the use of predictive modeling. However, as with any profiling method, there will be some good providers caught in the risk pool. While unfortunately, this will add cost for copying records and slow cash flow for the episodes selected, it should not result in denial of claims, and agencies should be spared additional scrutiny when proven correct.

 

About the Author

 

Bonny Kohr, RN, CHCE, HCS-D, is the manager of clinical services for FR &R Healthcare Consulting, Inc. She is a registered nurse, certified homecare coding specialist, and certified homecare and hospice executive. Bonny has worked 23 years in home health care, beginning as a field staff nurse, then as a clinical director, and finally as the chief operating officer.

 

Contact the Author

 

BKohr@frrcpas.com

 

To comment on this article please go to editor@racmonitor.com

Despite the fact that CMS has outlined the do's and don'ts for the Recovery Auditors (RAs) in its September 2011 "Statement of Work for the Recovery Audit Program,"1 we have come across several examples of contractors that have not met their contractual obligations. One would think that these RA "administrative errors" such as missed deadlines, incorrect addresses and the like would be sufficient basis for a sound appeal, but unfortunately, this does not seem to be the case. As we warned in our book, The RAC Toolkit for Hospitals and Health Systems, even when the RAs and other contractors don't play by the rules, a denial still may stand.

b-kohrConnolly Healthcare, the RAC contractor for Region C, has introduced an approved issue for home health review. The issue targets home health partial episode payments (PEPs) and involves automated reviews, which do not require contractors to obtain medical records from home health agencies. The intended purpose of the review is to identify agencies that have been underpaid.

 

PEP adjustments occur when a patient has been discharged and readmitted to the same home health agency (or transferred to another home health agency) within the same 60-day period. When an agency becomes aware of a PEP, it submits a discharge status code of 06 on the final claim for the first part of the 60-day episode. As a result, the claim is adjusted to pay a proportional amount based on the number of days of service provided.

On Wednesday, Dec. 21, 2011, CMS held an open-door forum on the upcoming RAC Pre-payment Demonstration Audits. Based on the discussion that ensued, CMS delayed the start of the RAC pre-payment reviews to on or after June 1, 2012 - and it's suspected that further clarification on some of the items brought up during the forum will be offered in the meantime.

 

As it stands today, these are the highlights of what has been outlined and where more clarifications may be made:

 

  • The following states will be included in the Pre-payment Demonstration: California, Florida, Illinois, Louisiana, Minnesota, New York, Texas, Missouri, North Carolina, Ohio and Pennsylvania.
  • The demonstration will run for three years, from Jan. 1, 2012 through Dec. 31, 2014. This likely will be updated, though, due to the delayed start.
  • Limits will not exceed the limits published for RAC post-payment reviews (so if a hospital has a 500-record request limit for post-payment, they also have a 500-record request limit for pre-payment, or a total of up to 1,000 requests possible every 45 days).
  • There is a 30-day turnaround time allotted for records; it is under discussion to extend this to 45 days to match the existing RAC process.
  • The requests will be made electronically by the Medicare Administrative Contractors (MACs) through the Medicare Direct Data Entry System (DDE), also known as the Common Working File (CWF) or the Florida Shared System (FSS). There will be no paper requests.
  • The requests could specify that records go to either the RACs or the MACs - it depends on the arrangements a RAC has made with the given MAC. The RACs will be doing all of the reviews.
  • It is likely that these requests will be billable to the RACs; for the demonstration CMS will confirm and post an update on this to the new website (http://go.cms.gov/cert-demos).
  • Contractors are starting with a limited number of eight DRGs. It's possible this list could change based on ongoing pre-payment audits being performed by the MACs. Those MS-DRGs include the following:
    • MS-DRG 312 SYNCOPE & COLLAPSE;
    • MS-DRG 069 TRANSIENT ISCHEMIA;
    • MS-DRG 377 G.I. HEMORRHAGE W MCC;
    • MS-DRG 378 G.I. HEMORRHAGE W CC;
    • MS-DRG 379 G.I. HEMORRHAGE W/O CC/MCC;
    • MS-DRG 637 DIABETES W MCC;
    • MS-DRG 638 DIABETES W CC; and
    • MS-DRG 639 DIABETES W/O CC/MCC.
  • These reviews will run parallel to MAC pre-payment reviews - for which there are no limits - and contractors are supposed to coordinate to ensure that they do not review for the same issues.
  • Providers can dispute duplicate requests they receive if for some reason the aforementioned coordination does not take place or does not work 100 percent of the time.
  • These records can be sent to the participating MACs and RACs electronically using esMD.

 

About the Author

 

Lori Brocato, HealthPort Audit Product Manager, has over 16 years of experience in the healthcare technology industry creating product lifecycle plans and executing product strategies. Ms. Brocato frequently serves as an audit expert sharing audit management trends and best practice guidelines as a regular presenter for industry events and webinars. She is the author of HealthPort's audit Insights Blog and provides expert input for many trade publication articles each year. Ms.Brocato holds the distinction of being RAC-certified by the Medicare RAC Summit and is a member HIMSS and HFMA.

 

 

Contact the Author

 

Lori.Brocato@healthport.com

 

To comment on this article please go to editor@racmonitor.com

 

Building a Best-Practices Approach to RAC Appeals

dr-r-wuebkerUnder Medicare guidance, and especially in the current audit environment, hospitals must have robust processes in place - not only for accurate DRG assignment, but also for compliant admission review as it pertains to medical necessity. Hospitals should understand their rights regarding claim appeals, gain an understanding of the Recovery Auditor (RA) appeal process and identify some strategies for mounting successful appeals.