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Audits & Assessments
Regulatory MonitoringAuthor Archive
Oct
15
HealthDataInsights (HDI) has announced two new issues for region D. HDI can now audit DME providers in all region D states for the following two issues:
- Urological bundling
- Wheelchair bundling
For more information on these issues, visit the HDI Web site.
As always, the latest RAC issues for each state are posted on the Revenue Cycle Institute ”Tools” Web page. Simply click the link at the top of the page to download a chart of RAC activity in your state.
Oct
01
The Revenue Cycle Institute has released a new White Paper, “Sepsis and Septicemia: Clear Up Coding and Documentation Confusion,” by Jennifer Avery, CCS, CPC, CPC-H CPC-I, regulatory specialist for HCPro, Inc.
In addition, each month the Revenue Cycle Institute publishes a free sample tool or form for readers. We hope you find this month’s tool helpful—an incident to audit checklist, courtesy of Elin Baklid-Kunz, MBA, CPC, CCS, the director of physician services for Halifax Health in Daytona Beach, FL, and JustCoding.com.
Both are free to download via the Revenue Cycle Institute Web site. To download the free White Paper, visit the Revenue Cycle Institute Web site and click on “White Papers.” To download the free tool, click on “Tools.”
Oct
01
CMS released the following new RAC FAQ September 25:
Q: How long is the RAC discussion period?A: The discussion period begins with the time of notification (demand letter for automated reviews and the review results letter for complex reviews) through the time recoupment occurs. The discussion period normally requires written notification to the RAC. The discussion period does not extend the provider's appeal time frames.
Sep
17
We’ve gathered the latest RAC information on the CMS-approved RAC issues in each state and put it together for you in a chart we hope you’ll find helpful.
Check back regularly; we’ll update the chart every time a RAC posts a new issue so you can always stay on top of the issues RACs may audit in your state as well as others in your region and across the country.
To view the chart, click on “Tools.”
Sep
17
CMS released on September 11 transmittal 302, which outlines the authority RACs, MACs, and other Medicare auditors have to apply exceptions to certain local coverage determination (LCD) clinically reasonable and necessary requirements. According to CMS, such exceptions should be rare and only under unusual circumstances.
The transmittal notes that during complex medical reviews certain auditors (e.g., MACs, RACs, and CERT) must apply LCDs made by fiscal intermediaries, carriers or MACs. However, in rare and unusual circumstances it may become necessary during such a review to apply an exception to the clinical criteria in applicable LCDs after a thorough review of the patient’s medical record and a comprehensive analysis of the evidence in medical literature.
Contractors other than RACs may apply an exception to either approve or deny a claim. RACs, however, may only use the exception not to deny the claim, according to the transmittal. Note also that exceptions may not be made for insufficient or missing documentation, and auditors may not make exceptions to national coverage determinations, MAC articles, or CMS manuals.
The changes are effective October 13.
Sep
17
Q: Several RACs are looking for once in a lifetime procedure coding errors. Wouldn’t Medically Unlikely Edits (MUE) help prevent a large number of these errors?
Sep
03
CMS updated the following three FAQ on August 26:
To read CMS’ answers, click on the links above. Visit the CMS Web site to see the entire list of RAC FAQ.
Sep
03
What’s the difference between a MAC and a RAC?
When it comes to protecting Medicare dollars, they share the responsibility of ensuring healthcare providers are paid correctly for services provided, and both conduct audits to help ensure as much.
But once a MAC audits a service, a RAC cannot. And visa versa. So does that mean there might be a little friendly competition between them?
Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC, who spoke during the August 13 audio conference, “Inpatient vs. Observation Service: Level of Care Compliance in a Challenging Regulatory Environment,” said she’s seeing a little bit of competition between MACs and RACs across the country. “We’ll have to see how this pans out,” she said. “But since those agencies do have the same responsibility, we may see more activity from the MACs than we do from the RACs.”
TrailBlazer, a MAC for Hale’s home state of Oklahoma, conducted an audit of 250 inpatient discharges for MS-DRG 247 (the DRG for coronary artery drug-eluting stent without a secondary diagnosis that counts as a major complication/comorbidity), according to a TrailBlazer Job Aid.
There was a 98.8% level of care error rate, according to the audit, meaning TrailBlazer recouped reimbursement in 98% of cases. “For most hospitals, that amount is in the $12,000 range,” Hale said. “That’s a pretty nice slice of reimbursement, and that leaves the hospital having to donate that drug-eluting stent at no charge.”
(The MAC denied 87% of the cases because it believed the provider should have performed the procedure in an outpatient, rather than inpatient setting. Another 11% were denied because providers didn’t submit requested medical records.)
And that’s not all. During a recent HCPro focus group call, one healthcare provider recently reported seeing a 70% increase in audit activity by commercial payers at their facility.
Just what every provider wants—more audits.
Editor’s note: We would also like to take a moment to welcome Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC to the RAC Report Advisory Board.
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