August 7, 2011

RAC Demand Letters Coming from MACs

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Providers should look for demand letters for recovery audit contractor-identified overpayments from their Medicare Administrative Contractors (MACs) starting Jan. 1, 2012.

CMS will require MACs instead of RACs to send demand letters and follow the same process for other payment recoupments, states Change Request 7436 issued July 29. During the RAC demonstration and national program until now, the RACs had been required to send demand letters.


MACs will be responsible for “administrative concerns,” such as timeframes for recoupment and the appeals process, but RACs will be responsible for “audit-specific communications,” including questions about a reviewer’s rationale, the change request states.

 

CMS Compliance Newsletter Highlights RAC Findings

CMS’s Medical Quarterly Provider Compliance Newsletter released Aug. 4 highlights eight RAC findings – seven for inpatient hospitals and one for durable medical equipment – that showcase common billing errors and provides guidance about how to avoid the problems. The issues are:

  • Multiple durable medical equipment rentals per month (DME)
  • Acute respiratory failure (inpatient hospitals)
  • Gastroenteritis with hemorrhage with complication and comorbidity (CC) or major complication and comorbidity (MCC) (inpatient hospitals)
  • Major cardiovascular thoracic aortic aneurysm repair procedures with CC or MCC (inpatient hospitals)
  • Intracranial hemorrhage or cerebral infarction (inpatient hospitals)
  • Post-operative anemia (inpatient hospitals)
  • Other vascular procedures with MCC: MS-DRG 252 (inpatient hospitals)
  • Peripheral/cranial nerve and other nervous system procedures with MCC:
  • MS-DRG 040 (inpatient hospitals)

 

Recent RAC Issues Posted

DCS Healthcare, the RAC in Region A, posted three issues this week – two issues affect Maryland inpatient hospitals and one issue affects professional service providers in all 11 Region A states and Washington, D.C.

RAC Regions B, C and D did not post new issues as of press time.

Inpatient Hospital

 

Name of issue Date posted or approved Regions/states where it is active Description of issue Document sources
Medical necessity review for MS-DRG 149 – vertigo and other labyrinth disorders (all severity and risk of mortality levels) 8/1/11 Md. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; Admission less than 24 hours policy; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730
Medical necessity review for MS-DRG 286,287 – cardiac catheterization for ischemic heart disease (all severity and risk of mortality levels) 8/1/11 Md. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; Admission less than 24 hours policy; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730

 

Professional Services

 

Name of issue Date posted or approved Regions/states where it is active Description of issue Document sources
National Correct Coding Initiative (CCI) – Part B 8/1/11 RAC Region A Application of the Part B National Correct Coding Initiative (Mutually Exclusive and Non-Mutually Exclusive). Deny Column II code when billed by the same provider and same date of service as a Column I code. CMS Pub 100-04

 

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

 

Comment on this Article

 

Read the Compliance Newsletter - http://www.cms.gov/MLNProducts/downloads/MedQtrlyComp_Newsletter_ICN903687.pdf

Karen Long

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