RACs Post 60 New Issues, 41 for Medical Necessity - Make Your Revenue Smarter


Region C List Riddled with Errors

Two of the CMS Recovery Audit Contractors (RAC) posted newly approved issues last week to their public websites, as required by CMS before widespread review of those issues can begin. Connolly Healthcare, the RAC for CMS Region C posted 36 new issues on their Approved Issues webpage, on Wednesday, February 9, 2011. Diversified Collection Services (DCS), the RAC for CMS Region A posted 24 new issues on their site. While DCS tends to post the most complete and accurate postings of the four RACs, Connolly continues to post confusing, incomplete and even erroneous information.

According to what we’ve been told by more than one individual recently, some providers have contacted CMS directly about the poor quality of the posts on the RAC public websites, which are presumably intended to inform and educate providers about past errors in their Medicare claims submissions, and hopefully help them avoid the same errors in the future. Nevertheless, the pleas of providers seems to have had no effect. CMS in fact has no authority to enforce any particular format on the RACs, since the final  Statement of Work mentions nothing about the format, much less the usefulness, of the webpages to be maintainted by the RACs. We have heard that suggestions have been made by CMS about how and what to post, but these appear to be non-binding on the RACs.

New Issues for DCS

Of the 24 new issues posted by DCS on Februrary 9, 10 and 11, there are 14 for Automated review (a computer program can detect such errors with accuracy) and 10 for Complex review (which requires a human to review the medical record to make judgements comparing the record with the bill submitted):

  • 7 issues for Automated review, concerning Professional Services (e.g., Physicians);
  • 5 issues for Automated review, concerning Hospitals;
  • 2 issues for Automated review, concerning DME providers;
  • 1 issue for Complex review, concerning DRG Validation covering 26 new MS-DRGs;
  • 6 issues for Complex review, for Medical Necessity covering 14 new MS-DRGs.

Completing that list are 3 new issues for something not seen on any of the RAC lists before: Medical Necessity Review for claims from DME providers. The issues cover Powered Wheelchairs, Pneumatic Compression Devices, and Air-fluidized Beds.

Region A providers should check the lists to be sure if their state is covered for any of the issues on the DCS site. Of all the RACs, DCS seems to be most likely to have only specific states approved for review of specific issues, in some cases only posting approval for a single state.

New Issues for Connolly

The site for Region C underwent two major changes last week. First, the site was reordered, placing the newest postings at the “top” of the page, and then listing all previous issues following those, but now in alphabetical order, according to the Issue Name. Previously, issues were simply added to the top of the page, which did at least provide an somewhat chronological order of the issue approvals. Dates of issue approval or issue posting are not (and never have been) provided by Connolly in these posts, despite requests for such from the provider community.

The second change was the addition of 36 new issues — one for DRG Validation, covering a mere 2 MSDRGs, and 35 for Medical Necessity review.

Good News, Bad News

The good news is that the Medical Necessity reviews all cover just single MSDRGs, which is a departure from many of the previous postings for Medical Necessity reviews by Connolly. Recently, several issues were posted with no MSDRGs called out in the issue descriptions, instead only including rather ambiguous titles that could be interpreted to include as many as 75 MSDRGs. Since then, Connolly has edited those postings, adding a list of MSDRGs to some of the issues in question, but then removing the lists completely, only a few days later. There does not seem to be any coherent explanation being presented, so far. At least some providers appreciated seeing MSDRGs listed in last week’s postings. The appreciation was short-lived, however.

The bad news about the postings is that although each one only covers a single MSDRG, the descriptive text in the Issue Names does not often correspond to the MSDRG called out in the title or description.

For example, consider this posting:

Issue Name: Medical Necessity: Acute Inpatient Admission Respiratory Conditions, MS-DRG 501

The MSDRG has nothing to do with Respiratory Conditons. MSDRG 501 is for Soft Tissue Procedures. So what is the issue being audited — Soft Tissue Procedures or Respiratory Conditions (which could arguably include any of 34 MSDRGs)? Nothing else in that particular post helps clear up the confusion.

The next issue listed has a different title, but is close to the previous DRG:

Issue Name: Medical Necessity: Acute Inpatient Admissions, MS-DRG 502

This post has nothing in the title or description to define the issue, except the MSDRG number itself. Perhaps the answer then, is to ignore the partial description in the title. This seems to make sense, since the two MSDRGs are two of a triplet, MSDRGs 500 (Soft Tissue Procedures with MCC), 501 (Soft Tissue Procedures with CC) and 502 (Soft Tissue Procedures without CC/MCC).

At first glance, it might seem fairly simple to resolve the question of which issue is being audited. Or, put another way, what the contractors”mean” by what they write (post) in their documentation (pages or sites). Providers might recognize this argument. It’s similar to the one that physicians sometimes make when discussing their documentation in the medical record.

So the question arises:  does accuracy only count for providers? Some consider it ironic that the very contractors who hold providers responsible for being 100% accurate are themselves not being held accountable for their own accuracy rate.

Last week’s postings by Connolly, if audited in a manner similar to audits of Medicare claims, then Connolly’s error rate approached 45% (16 errors in 36 posts).

 

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