Demystifying the query development process is key to every healthcare provider's success, regardless of the type of services being delivered. It requires an understanding of the resources, references and tools used by RACs, allowing providers to initiate their organizations' preparation for CMS audit "participation."
The tools used by RACs are many, and grouped together they may look like alphabet soup. The "new issue" process begins with the responsible team's identification of potential billing/reimbursement issues. The typical "new issues" team is comprised of experienced claims processing representatives with specific backgrounds in Part A, Part B, DME, pharmacy, home health, hospice, hospital care, provider operations, SNFs and/or other areas. This team uses its collective experience and multiple resources to identify potential issues on which analysis will be performed.
In addition to relying on experience, RACs use the following data sources (the alphabet soup):
- Raw data - RAC databases, routine CMS RAC Data Warehouse downloads, industry trends;
- Outcome reports - CERTs(1), OIG(2), PEPPER(3), GAO(4), QIOs(5);
- Industry experience(6) and information - AAHAM, AHA, AMA, AAASC, JCAHO, JCAHACO;
- Policy/rules and regulations(7) - LCDs, NCDs, CRs(8), IOMs, MLN; and
- CMS programs - ZPICS(9), DOJ(10), vulnerabilities reports(11), carriers, FIs, MACs.
Information is collected and evaluated to determine potential improper payment trends, types of provider(s) involved, resources and financial impacts, and projected outcomes. Data is analyzed by statisticians and/or SAS analysts to define each of these elements by targeted provider type(s). Once analytical results are provided to the new issue team, the list of improper payments is prioritized and the new issue submission type/preparation begins.
Different submission criteria exist for new issue automated reviews (examples of findings and results required) and new issue complex reviews (medical record documentation and evaluation findings required). The RACs' preparation and submission processes vary due to CMS Review Board supportive information/analytical requirements, and these processes can range in length from 30 to 120 days prior to RAC submission to CMS.
All new issues require complete data presentation with projected Medicare Trust Fund returns. The CMS new issues submission package is well-defined, and submissions must meet all specifications before presentation to the CMS Review Board is made. If a new issue package fails to fulfill any defined criterion, it is returned to the RAC for review and re-submission (this means the RAC loses a place in line for the CMS Review Board's review/approval of a new issue). In 2010, the CMS New Issues Review Board had an ever-enlarging new issues backlog, resulting in their encouragement that all RACs collaborate on a list of issues for board consideration. RACs embraced the recommendation and drafted eight new issues for collaborative submission to the CMS Review Board.
(1) Comprehensive Error Rate Testing (CERT) Program reports (www.cms.gov/CERT/CR/LIST.asp). Link lists reports by hear and report type, i.e., over utilized codes, CERT findings, use corrective actions to monitor improper payment findings. This website usually is accessible from carrier/FI/MAC website link.
(2) Office of Inspector General Reports (www.hhs.gov/reports.asp).
(3) Program for Evaluating Payment Patterns Electronic Report (PEPPER); published by TMF Health Quality Initiative under contract with CMS. Audio on demand for PEPPER information; PEPPER 2011: Identify Changes, Address Vulnerabilities and Be Audit-Ready.
(4) General Accounting Office "GAO" reports (www.gpoaccess.gov).
(5) Quality Improvement Organization reports (www.cms.gov/QualityImprovementOrgs/).
(6) Inpatient, ambulatory, outpatient, DME, SNF, CORF, rehab, hospice, physician, etc.; www.beckerhospitalreview.com; high-risk coding errors, duplicate claims, pricing errors, billing excessive units, failure to meet LOC requirements, payment errors, SNF consolidated billing, crossover coverage (ambulance, medications), questionable level of care, improper diagnosis codes, mismatched codes, etc.
(7) Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) (www.cms.gov/medicare-coverage-database/).
(8) CMS change requests (www.cms.gov/Transmittals/downloads).
(9) Zone Program Integrity contractor - ZPICs (former Program Safeguard Contractors) (www.zpicaudit.com).
(10) U.S. Department of Justice (www.justice.gov/oig/reports/index.htm).
CMS Review Board
Upon receipt of a new issue package, designated CMS Review Board representative(s), review it for submission compliance, content, new issue review type (automated/complex), value (financial returns) and review submission direction. The new issue package also may be presented to the RAC validation contractor for assessment and recommendations and/or to the CMS Review Board (physicians, policy makers, etc.). Once reviewed, the CMS board renders a decision, ruling from the following list of options:
- Approved as submitted.
- Approved with modifications.
- Approved with defined limitations.
- Denied for current review period, resubmit in one year.
Approved new issues are posted on the RACs' provider portals and are made available for RAC inclusion in future audits.
About the Author
Vickie Axsom-Brown is a 20-year managed care veteran with diverse experience in administering private, state and federal healthcare services. Her management experience includes time spent as the vice president of Region D RAC services (as the principal lead for CMS, claims processing contractors and HDI services) and as CEO/COO of multidisciplinary, multi-site adult and pediatric medical/surgical providers, including oncology/radiology services, laboratory services, ambulatory surgery centers, upright MRIs, PETs, and others.
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