Top Ranked, High Dollar DRGs Added
It comes as no surprise that many of the DRGs added to the list are aimed at high-dollar claims, given Connolly's demonstrated proclivity to review high-dollar DRGs. You can see our recent analysis published in RAC Monitor just last week, HERE.
We note a couple of interesting facts about these new issues:
- Of the 52 DRGs with Relative Weights greater than 5.0, Connolly just added four (4), bringing their total to eight (8) of the highest paying DRGs being reviewed by Connolly;
- Six(6) of the 19 new issues are ranked (by number of discharges) in the top 100 DRGs nationwide;
- Fifty eight percent of the 19 new issues have Relative Weights greater than 2.0 compare that to only 26 percent of all DRGs, showing a very definite continuing preference to review high-dollar claims.
Medical Necessity Still Excluded, At This Time
None of the posted issues are approved for review of Medical Necessity, but still include the caveat, "at this time." To date, none of the 550+ DRG Validations issues approved for all the RACs have included review of Medical necessity. However, the RACs have now stacked the deck in their favor, so to speak.
What Happens When Medical Necessity is Approved for Review?
Consider these facts about what the situation will be like, once medical necessity is finally approved by CMS for review by RACs:
- RACs will already have many records in hand being reviewed for DRG Validation;
- DRG Validation actually does in fact involve review of medical necessity, per CMS instructions in the PIM (see Chapter 6.5.4, the one they haven't mentioned, so far);
- RACs won't even have to make additional ADRs (Additional Documentation Requests) to do medical necessity reviews for records they already have in hand;
- Medical necessity reviews for all existing DRG Validation issues are likely to be approved in short order, since the CMS RAC Review Phase-In Strategy calls for this in calendar 2010.
- Records already in hand do not count toward the ADR Limits just approved by CMS -- so the RAC can issue more ADRs, every 45 days.
In other words, when medical necessity is approved, the RACs will already have done those reviews, and will likely be even better prepared to do more, immediately.
Three States Added to Previously Posted Issues
Previously, Connolly posted most of their DRG Validation issues as approved for review in only 10 of their 13 states. However, on February 2, the last three states under their purview - Arkansas, Louisiana and Mississippi- were added to the states affected lists for all previously approved DRG Validation issues, now bringing them fully under the magnifying glass of the RAC.
More Useful Lists Are Available
Several providers have told us that they have sent written requests to Connolly to make their approved issues list more "user-friendly." Connolly's response, we are told, was "we'll take it under consideration." Also, we've heard that CMS has responded to similar provider requests, saying that the format of the published lists is "not included in the Statement of Work" - meaning, we suppose, the formats are not specified by CMS, and therefore the RACs are able to provide the lists in whatever format they decide to use. The result, of course, is that each RAC uses a completely different format.
We think it is not very likely that those formats will become more usable. After all, since the RACs only get paid if THEY find erroneous payments, it behooves them to do as little as possible to help the providers find the errors beforehand. If a provider finds an error in an internal audit and self-discloses those errors to CMS before a RAC finds those same errors, then the RAC gets nothing.
Nevertheless, the Statement of Work does require the RACs to post all their approved issues on public Web pages, before they can begin sending out records requests for demand letters. They do now publish such pages, and links to all the RAC New Issues Pages can be found here.
For more useful lists, see below.
Use the links below to see details of the newly posted issues, in our database (Note: this list appears here in the reverse order as posted by Connolly):
To find a list of all of Connolly's posted issues, go HERE. (Registration required.)
A version of these lists that can be downloaded (as a CSV file) is coming soon. Stay tuned!
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