All Entries Tagged With: "contractors"
RACs and medical necessity criteria
Q: If my hospital is not using the latest InterQual criteria, could that chart be pulled by the RAC for fraud?
A: InterQual is merely a screening criteria—CMS doesn’t actually require hospitals to use it. Therefore, use of an older version or a different set of criteria such as Milliman is not inherently a problem. However, because outside entities such as RACs, MACs or QIOs will be reviewing cases, most hospitals choose to use the same version used by their contractors (presumably the version for the year applicable to the case). Additionally, outdated versions may not reflect advances in care and may cause inappropriate screening decisions.
Note that a patient may not meet InterQual inpatient criteria, but still be considered an inpatient upon physician review. InterQual is a screening criteria—it screens for the most likely inpatient and outpatient admissions, but can not take into account every medical circumstance. There are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician’s review will nevertheless be appropriate for inpatient admission.
For this reason, each permanent RAC will now have at least one physician medical director who will be involved in developing evidence for individual claims determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claims denials.
In addition, RACs do not audit for fraud. Their only task is to look for overpayments and underpayments, either due to errors by the hospital or by CMS’ processing systems. RACs are simply looking for incorrect payments, no matter whose fault, and getting that money back to the Medicare Trust Fund after taking their cut. Of course, if a RAC believes it uncovers a fraudulent scheme or set of practices, it may make an appropriate referral to one of the contractors monitoring for fraud, but it is not a part of their scope of work.
Editor’s note: This question was answered by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc. It was originally published in The RAC Report, a bi-weekly HCPro e-newsletter.
It is also important to note that not all RACs will be using InterQual for claims investigations. HealthDataInsights, the RAC for 17 Western states, has declared it will be using Milliman Care Guidelines content and software to review Medicare claims. You can read more about that in a March 3 article published in Reuters.
Does your facility use InterQual, Milliman, or something different? Feel free to share your thoughts and experiences.
CMS, RACs, POA, LOS–but what about the patient?
Boy is healthcare ever on a fast track and getting more complex and confusing. There are new and revised regulations coming from the Centers of Medicare and Medicaid Services (CMS), and the Recovery Audit Contractor (RAC) implementation has us going to more meetings than we know what to do with. Let’s not forget about Present on Admission (POA) and we need to be monitoring those lengths of stay (LOS). Don’t get me wrong, these are all very important, high priority issues, but what about the patient?
[more]
