What’s New with MAC, RAC, Medicaid
and the OIG?
Audit findings, Updates, and Operational Ideas
Instructor:
Day Egusquiza, Pres
AR Systems, Inc
RAC 2012
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To ensure billed services are reflected in the
documentation in the record
To ensure billed services are in the medically
correct setting for the pt’s condition
To ensure billed service reflect the ‘rules’
regarding billing for the specific service
To ensure documentation can support all
billed services according to the payer rules.
RAC 2012
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Common issues:
◦ Dept staff not understanding the charge capture
must match physician order and documentation.
◦ Lack of ongoing coder education
◦ Lack of ongoing dept head ed
◦ Lack of physician understanding
◦ Creating a culture of audit – time to be pro-active
RAC 2012
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Commitment to Reduce the Error
President Obama recently announced the
government’s commitment to reduce the error
rate by 50% (using a baseline of 12.4%) by 2012
(2008 3.6% $10.3 Billion )
– 9.5% for November 2010 Report
– 8.5% for November 2011 Report
– 6.2% for November 2012 Report
Thru MAC, CERT, ZPIC, RAC, MIC, OIG, HEAT auditing…
Funding PPACA by eliminating fraud, waste and abuse…
RAC 2012
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Entity
Type of
claims
How
selected
Volume of
claims
Purpose of
review
QIO
Inpt hospital
All claims where
hospital submits an
adj claim for a
higher DRG.
Expedited coverage
review requested
by bene
Very small
To prevent
improper payment
thru upcoding.
To resolve disputes
between bene and
hospital
CERT
All
Randomly
Small
To measure
improper payments
MAC
All
Targeted
Depends on # of
claims with
improper payments
To prevent future
improper payments
RAC
All
Targeted
Depends on the #
of claims with
improper payments
To detect and
correct past
improper payments
PSCZPIC
All
Targeted
Depends on the #
of potential fraud
claims
To identify
potential fraud
OIG
All
Targeted
Depends on the #
of potential fraud
claims RAC 2012
To identify Fraud
5
Updates Impacting the
Auditing of Claims
RAC 2012
6
Demonstration
Pre-Payment
Review –focused
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7 states with high fraud and
error prone providers: FL,
CA, TX, MI, NY, LA, Ill
4 states with high volume
of short stay hospital stays:
PA, OH, NC. MO
Does not replace Pre for
MACs
Should allow for more timely
rebills of corrected claims while
catching potential patterns early.
REACTIVATED: Go live June
2012
Prior authorization of certain
medical equipment.
(www/cms/gov/apps/media/
Press/factsheet.asp?counter
Part A to Part B Rebilling
 380 hospitals /pilot can
sign up to volunteer
 All hospitals to resubmit
claims for 90% of the
allowable Part B payment
when RAC, CERT, MAC finds
that a Medicare pt met Part
(www/cms/gov/apps/me
B, not Part A.
 NO APPEAL RIGHTS if join
dia/
this demonstration project.
 Can opt out at any time.
RAC 2012
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Limitations on prepayment
won’t exceed current post
payment ADR limits.
Medical records provided
on appeal will be remanded
to the RAC for review
Claims will be off limits
from future post payment
reviews
ADR letter will advise where
to send: RAC or MAC.
30 days to reply
June 1 – 312/Syncope
 Aug 1 – 069/Transcient
Ischemia; 377/GI
hemorrhage w/MCC
 Sept 1 – 378/GI
Hemorrhage w CC; 379/GI
Hemorrhage w/o CC/MCC
 Oct 1 – 637/diabetes
w/MCC; 638/diabetes
w/CC; 639/diabetes w/o
CC/MCC
RAC @cms.hhs.gov
//go.cms.gov/cert-demos
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RAC 2012
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Highlights
◦ Allows /outlines Semi Automated Reviews
◦ RAC decisions beyond 60 days = no payment to the
RAC but can request an extension.
◦ Discussion period continues but no timelines for
replies from the RAC. Should be in writing and
responded to within 30 days of receipt. If appeal is
filed, discussion period ends.
◦ Posting of new issues still a problem with HDI and
Connolly. But no new guidelines for the RACs
◦ Timely period between results letter and demand
letter . (Estimated at 2 weeks)
(CMS’s website, posted 9-1-11)
RAC 2012
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Effective March 15, 2012, calculation for record count has
increased.
“The limit is equal to 2% (use to be 1%) of all claims submitted
for the previous calendar year divided by 8. EX) billed
156,253 claims, 2% = 3125 /8 = 390 every 45 days”
“RAC can request up to 35 records per 45 days for providers
whose calculated limit is 34 or less”
“Maximum # of records per 45 is 400” (was 300)
“Providers with over $100,000,000 in MS-DRG payments who
had the 500 requests cap will now have a 600 record cap”
Hospital feedback on 3-16: GA “went up 118%; Al doubled,
Texas up by 100 records each 45 days, NC up by 87 records,
IN 300-400 between our 3 hospitals.”
RAC 2012
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Semi-automated reviews are a two-part
review that is now being used in the Recovery
Audit Program. The first part is the
identification of a billing aberrancy through
an automated review using claims data. This
aberrancy has a high index of suspicion to be
an improper payment. The second part
includes a Notification Letter that is sent to
the provider explaining the potential billing
error that was identified.
Still no limit on requests; in addition to
complex record requests.
RAC 2012
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Region
Overpaymts
($ in
millions)
Underpaymt
Total 3rd Q
Corrections
(Based on
actual
collections
FY to Date
Corrections
Data thru
June 30,
2011)
Region A
DCS
$40.4
$5.0
$45.4
$98.2
Region B
CGI
$33.9
$9.8
$43.7
$118.5
Region C
Connolly
$46.9
$7.4
$54.3
$133.3
Region D
HDI
$112.2
$33.7
$145.9
$242.5
TOTALS
$233.4
$55.9
$289.3
$592.5
RAC 2012
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Region A: Renal and Urinary Tract Disorders
(Not medically appropriate for inpt status)
Region B: Extensive Operating room
procedures unrelated to principal dx (DRG
validation – primary and 2nd dx errors)
Region C: Durable Medical
Equipment/Prosthetics/DMEPOS (Automated
review – no separate payment when inpt.)
Region D: Minor surgery and other treatment
billed as an inpt (Not medically appropriate
for an inpt status.)
HDI purchased by NY based HMS Holdings $400M. 11-11
RAC 2012
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Region
Overpaymts
($ in
millions)
Underpaymt
Total 3rd Q
Corrections
(Based on
actual
collections
FY to Date
Corrections
Data Oct
2010-Sept
30, 2011)
Region
A/DCS
$ 43.3
$ 5.8
$ 49.1
$146.3
Region
B/CGI
$ 60.4
$ 3.2
$ 63.6
$170.3
Region
C/Connolly
$ 65.2
$ 60.7
$125.9
$260.9
Region
D/HDI
$108.2
$ 6.9
$115.1
$361.8
Nationwide
Totals
$277.1
$ 76.6
$353.7
$939.4
RAC 2012
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Region A: Renal & Urinary Tract Disorders
(medically necessary/incorrect setting)
Region B: Surgical Cardiovascular
Procedures (medically necessary)
Region C: Acute inpt admission neurological
disorders (medically necessary)
Region D: Minor surgeries and other
treatment billed as an inpt (medically
necessary ) *When pts with known dx enter a hospital for a specific
minor surgical procedure and is expected to keep them les than 24 hrs, they
are considered outpt regardless of the hour they present to the hospital,
whether a bed was used or whether they remain after midnight.
RAC 2012
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After many confusing/delayed RAC recovery and demand
letters, CMS has made the following change.
“Effective Jan 3, 2012, CMS is transferring the responsibility for
issuing demand letters to providers from its Recovery Auditors to its
claims processing contractors. This change was made to avoid any
delays in demand letter issuance. As a result, when a Recovery
Auditor finds that improper payments have been made to you, they
will submit claim adjustments to your Medicare contractor. Your
Medicare contractor will then establish receivables and issue
automated demand letters for any RAC identified overpayment.
The Medicare contactor will follow the same process as is used to
recover other overpayments. The Medicare contractor will then be
responsible for fielding any administrative concerns you may have
with timelines, appeals, etc.”
Messy: Letter to MAC/FI’s contact, not the RAC contact. Yell !
Details as to the reason/pt identifier are missing. Not required.
RAC 2012
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•
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Focusing on curbing fraud, waste and abuse in the Medicare
program.
Time period for filing Medicare FFS claims in Section 6404 of the
PPACA amended the timely filing requirements to reduce the
maximum time period for submission of all Medicare FFS claims
to one calendar year after the date of service.
Under the new law, claims for services furnished on or after Jan
1, 2010 must be filed within 1 calendar year after date of service.
In addition, mandates that claims for services furnished before
Jan 1, 2010 must be filed no later than Dec 31, 2010.
The following rules apply to claims with dates of service prior to
Jan 1, 2010: claims with dates of service before Oct 1, 2009
must follow the pre-PPACA timely filing rules. Claims with dates
of service Oct 1-Dec 31, 2009 must be submitted by Dec 31,
2010.
Impact on denied claims with rebill potential with the RAC and
MIC?
MESSAGE: GET IT RIGHT THE FIRST TIME.
RAC 2012
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Requires report and repayment of
overpayments.
“Overpayment’ = funds a person receives or retains to which
person is not entitled after reconciliation.
Providers and suppliers must: Report and return
overpayments to HHS, the state or contractor by the later of:
◦ 60 days after the date the overpayment was identified or
◦ The date the corresponding cost report is due.
Provide a written explanation of the reason for overpayment
(PPACA 6402)
Retaining overpayments after the deadline for reporting is
subject to False Claims Act and Civil Monetary Penalties
law.
RAC 2012
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SE1024 “RAC: High Risk Vulnerabilities- No
documentation or insufficient
documentation submitted” (July 2010)
Two areas of high risk were identified from
the demonstration project:
No reply to request/timely submission (1
additional attempt must be made prior to
denial)
Incomplete or insufficient
documentation to support billable services
RAC 2012
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SE1024/July
No documentation or insufficient documentation
submitted
SE1027/Sept
Medical necessity vulnerabilities for inpt hospitals
SE1028/Sept
DRG coding vulnerabilities for inpt hospitals
SE1036/Dec
Physician RAC vulnerabilities
SE1037 /Jan 11
Guidance on Hospital Inpt Admission
(referencing CMS guidelines, does not mandate Interqual/Milliman,
RAC judgment allowed)
SE1104/Mar 11 Correct Coding POS/Physicians
Special Edition #SE1121/June 11 RAC DRG
Vulnerabilities –coding w/o D/C summary
SE1210/Mar 12
RAC with MN of Renal & Urinary Tract Disorders
RAC 2012
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CMS refers hospitals to Medicare
Program Integrity Manual and
reiterates that CMS requires
contractor staff to use a
screening tool as part of their
medical review process of inpt
hospital claims. While there are
several commercially available
screening tools…such as
Milliman, Interqual and other
PROPRIETARY systems… CMS
does not endorse any particular
brand.
CMS repeats that contractors are
not required to automatically pay
a claim even if screening
indicates the admission was
appropriate and conversely,
contractors are not automatically
to deny claims that do not meet
screening tool guidelines
 “In all cases, in addition to the
screening instruments, the
reviewer shall apply his/her own
clinical judgment to make a
medical review determination
based on the documentation in
the record.”
 The guidance restates that the
Medicare Benefit Policy Manual,
Chpt 1, instructions that a
physician is responsible for
deciding whether the pt should
be admitted as inpt.
RAC 2012
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Determining correct status
Clarifying order of the status
◦ Examples of weak orders: Admit to Dr Joe, Admit to tele, Transfer
to the floor, admit to 23:59, admit to medical service, admit to
FIT. None clearly define : Admit to inpt status and why –add
(intent of the order)
Directing the clinical team as to the intensity of services that need
provided when the pt ‘hits the bed’ as well as thru the course of
treatment.
42 CFR 482.12 (c) (2) “Patients are admitting to the hospital only
on a recommendation of a licensed practitioner permitted by the
state to admit pts to the hospital. “
Medicare State Operations Manual “In no case may a nonphysician make a final determination that a pt’s stay is not medically
necessary or appropriate.” Case Mgt protocol can ‘recommend’ to
the providers but only takes effect when the provider has
authenticated it.
RAC 2012
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Many facilities are using outside physician
advisors or are growing their own advisors –
many times the UR physician.
Ensure that any 2nd opinion by a nontreating provider is ‘validated’ and used for
directing care by the attending/admitting.
Otherwise it is just another non-treating
opinion. Additionally, look for educational
opportunities thru patterns --dx,
documentation, doctor.
Double check with the QIO for their opinion during audit.
RAC 2012
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2-11 CMS announced a revised threshold
for hospitals with $100 million in Medicare
payments. The cap was raised to 500 per 45
day period, up from the 300 cap. AHA
expressed concern over the 87 hospitals that
will be impacted by this change. (New #, 3-12, 600)
PIP hospitals will begin to have records
requested 2nd Q 2012.. Many PIP hospitals are
large hospitals who could easily have their
first record request be 500 records.
RAC 2012
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All RACs have begun doing (4-11)
Using the automated review/data mining to identify
billing abnormalities with a high potential for
improper payment.
This is followed by a request for records/complex
to audit to determine if an error did occur in
charge capture or claim’s submission.
EX) Tx hospital: Cataract removal can occur once
per eye for the same date of service.
66984/removal with insertion of lens AND 6701059 removal with mechanical vitrectomy) created the
edit. 59 overrode edits = 2 payments.
RAC 2012
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Connolly, 5-11
Remicade billed
w/chemo drug adm
CPT codes
Letter says: “Data
analysis showed an
aberrant billing pattern
inconsistent with a
policy. “
Unknown limit, not
subject to complex
limits
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Connolly, 5-11
Letter for at least 100
claims.
Infliximab –is a
monoclonal antibody
agent. Drugs “may’ be
administered using the
chemo therapy CPTs.
Reply with records
within 45 days, same
penalities
RAC 2012
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As of 2-14-11, modified changes
Limits based on physician or non PP’s billing Tax ID
# as well as the first three positions of the ZIP code
where that physician/non PP is physically located.
EX: Group ABC has TIN 12345 and two physical
locations in ZIP code 4567 and 4568. This group
qualifies as a single entry for additional
documentation requests/ADR.
Ex: Group XYZ has TIN 12345 and two physical
locations in ZIP 4556 and 5566. This group would
qualify as two unique entities for ADR
RAC 2012
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ADR limits will be based on the # of individual
rendering physician/non-PP reported under each
TIN/ZIP combination in the previous calendar year.
Reserves the right to exceed the cap if indicated.
Group/Office Size
Maximum # of requests
per /each 45 days
50 or more
50 records
25-49
40 records
6-24
25 records
Less than 5
10 records
RAC 2012
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Place of Service – outpt hospital vs office
(SE1104 Med Learn; 11 vs 22 or 23)
Separate E&M leveling within the surgical/CPT bundle period
New vs Established
Level of service conflicts with the hospital – doc /inpt;
hospital/OBS
Based on CERT audit results/ West coast, the following was
targeted for audit: (2011)
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99214
99223 (Initial day)
99233 (Subsequent hospital visit)
Cert audits can trigger requests for records if provider history
shows an abnormal volume/risk for targeted CPT codes
Office E&M leveling is not a focus of the RAC audits..yet
RAC 2012
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…can be the same material as the RACs.
Ex. Az hospital had a ST MUE error. They received
automated demand letters from HDI; however, they
also received ‘first notice’ from WPS on the same
issue. Per WPS, the site has 30 days from receipt of
the WPS letter without interest to repay or be
recouped on the 41st day with interest.
No published items; no limits on requests, same
appeal rights. Letters SOMETIMES explain..
WPS – Prepayment 310, 313, 192, 690
NHIC – Prepayment auditing of Chest pain,
syncope and collapse, CHF.
RAC 2012
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Noridian/J3 has announced Probe audits for
AZ, MT, ND, SD, UT, WY
Probe for 1 day stays, 2 day stays, 3 day stays
and high dollar (w/o definition of $)
Noridian was awarded JF MAC on 8-22-11
Includes ID, ND, Alaska, WA, Ore, SD, MT, WY,
UT and AZ. Look for more wide spread
auditing. Using CERT data for more probes
NGS – Mobile CMS audits/NY & Prepayment
(2012) No letters with reasons.
RAC 2012
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Highmark (Now Novitas Solutions)
◦ Probe for DRG 470/Major Joint Replacement or
reattachment of lower extremity w/MCC. Need to document
6 months of failed conservative therapy!!
◦ Probe for DRG 244 Permanent Cardiac Pacemaker implant
w/o CC or MCC.
◦ NEW: 313, 392, 292 (2012)
◦ Msg from provider: Have been having 100% prepayment
audit payment for DRG 313/chest pain for almost 2 years
now. The site indicates they are being successful around
90% of time at the 3rd level appeal/ALJ but it is taking about
18 months. There does not appear to be a change with the
pre-payment review even with the overturn rate. (per PA
facility history 9-11)
RAC 2012
32
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Trailblazer/TX highlights
◦ Developed LCD 41-96SAB for Hydration (9636061)
◦ Reviewing DRG appeals and determining patient
status was incorrect. Denied entire inpt stay.
◦ Issued 5 DRGs that will be on prepayment review:
243, 246, 247, 460, 470 (Ex: Stents, pacemaker)
◦ 2011- Lost MAC bid. Highmark awarded. 1/12 –
Highmark ‘s Medicare Division , MAC J12, was sold
to BC/BC of FL (BCBSF) with their subsidiary, First
Coast who is a MAC J9.
RAC 2012
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Trailblazer: to increase consistency in
Medicare reimbursement, effective 11-11,
Trailblazer will begin cross-claim review of
these services. The related Part B service
(E&M, procedures) reported to Medicare will
be evaluated for reimbursement on a post
payment basis. Overpayments will be
requested for services related to the inpt stay
that are found to be in error.
First Coast & HighMark/Novitas– similar
RAC 2012
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Palmetto, Pre Payment Auditing
Began early 2012
DRGs focus:
◦
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871
641
690
470
Septicemia/Sepsis
Misc disorders of nutrition
Kidney / UTI
Joint replacement
Site: CA site. Prior to Feb, 2012 – never had a prepayment audit request. Had 12 in 1st request.
RAC 2012
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Cahaba – Pre-Auditing of the below DRGs.
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069
191
195
247
287
313
392
552
641
945
470
(2-12)
(Transient Ischemia)
(Chronic Obstructive Pulmonary Disease w CC)
(Simple Pneumonia & Pleurisy w/o CC/MCC)
(Percutaneous Cardiovascular Procedure w Drug-Eluting Stent w/o
MCC)
(Circulatory Disorders Except AMI, w Cardiac Cath w/o MCC)
(Chest Pain)
(Esophagitis, Gastroenteritis & Misc Digestive Disorders /o MCC)
(Medical Back Problems w/o MCC)
(Nutritional & Misc Metabolic Disorders w/o MCC)
(Rehabilitation w CC/MCC)
(Joint replacement)
RAC 2012
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DRG
Description
2009 Error Rate
2010 Error Rate
313
Chest pain
55.16%
76.71%
552
Medical back pain w/o
MCC
70.92%
71.25%
392
Gastro & misc disorders
w/o MCC
49.08%
41.93%
641
Nutrition misc metabolic
disorder w/o MCC
49.27%
48.43%
227
Cardiac defib w/o cath lab
w/o MCC
20.65%
45.43%
RAC 2012
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“Louisville, KY based Norton Healthcare agreed to pay the
federal govt $782,842 in March to settle allegations that it
overbilled Medicare for wound care, infusion and cancer
radiation services by adding a separate E&M charge that
should have been included in the basic rate. The alleged
overbilling, which occurred between Jan 2005-Feb 2010
involved outpt care. The settlement is twice the amt Norton
allegedly overbilled.”
ISSUE:
Transmittal A-00-40, A-01-80 indicate that there
is inherent nursing in all CPT codes. Therefore, the facility
must ‘earn an E&M when done with a procedure.’ Unlikely
events, other medical conditions being treated, new
pt=examples.
RAC 2012
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Outpt claims pd greater than
charges. (APC methodology)
Inpt claims pd greater than
chgs
Inpt $ greater $150.000
Outpt $ greater $25,000
One day stays at acute care
Major complications /comorb
Payments for septicemia servs
Payments for inpt same day
discharges and readmissions
Outpt claims billed during the
DRG payment window
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Payments for hemophilia
Payments for outpt surgeries
w/units greater than 1
Inpt and outpt claims
/manufacturer credits for
replacement of devices
Post –acute transfers to
SNF/HHA/another acute care
inpt facility
SNF/HHA consolidated billingseparate outpt services
Outpt claims with 59 modifier
Inpt claims pd greater than
chgs
39
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2-1-11 CMS Bulletin
RAC for Medicaid
postponed
9-14-11 CMS issued
new RAC for Medicaid
final rules
Patterned after Medicare
RAC – 3 yr look back,
prohibits auditing done
by another group, set
limits on medical record
requests, notify of
overpayment in 60 days
and coordinate.
www.ofr.gov/ORFUpload/OFRdata/2
011-23695 PI.pdf
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2-16-11 CMS
proposes Medicaid
payment reductions for
provider-preventable
conditions
Follow Medicare’s
hospital acquired
conditions
Allow for additional
conditions for
reduction, state
specific
RAC 2012
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1) Medicaid integrity contractors – CMS has
established a 5 year look back period with 30 days
to reply to requests for record (10-1-10)
2) RAC for Medicaid – Final rule out Sept 14, 2011.
To have in place by Jan 1, 2012. Target: $2.1B,
with $900M to the states
3) State Medicaid – state fraud units are auditing
and coordinating all data for audits.
Concern – avoid duplication! 3 unique
groups. Track and watch each one
separately.
NOTE: Medicare RACs are also becoming
Medicaid RACs. (HDI-Ks)
RAC 2012
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OB – protocols
Physicians/extended must order/direct pt
care, pt specific.
Protocols are excellent clinical pathways, but
the physician must order the protocol.
EX) Pt is 26 weeks. Nursing implements
protocol for under 27 weeks. Doesn’t call the
provider until results from first items on the
protocol. Not billable. Must contact the
provider to initiate protocol , then follow
protocol. Billable.
RAC 2012
42
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CERT audits have continued to identify
weakness in the use of Protocols.
EX) Lab urine test ordered but culture done as
2nd test due to protocol. (Noridian/Nov 2009)
EX) Without contrast but 2nd one done with
contrast based on protocols.
Ensure the order is either updated or the initial
order clearly states ‘with protocol as
necessary.”
YEAH – how about including the protocols that are
referenced in the record when submitting for audit?
RAC 2012
43
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N432 = means 2 different things on the RAs.
◦ Pending recoupment, should coincide with the Demand
letter
◦ Actual recoupment, 41 days after the demand letter which
should include interest from the 31-41st days
◦ Remark codes from transmittal 659 clarify
N469 = CERT and MAC denials (Per MAC/NGS training on 311) Also used when postponing recoupment/Transmittal
141.
MAC accepted the payment (within 30 days) and did the
recoupment on the 41st day too! (GA)
Transmittal 659/CR 68709
PLB reason code (FB ) forward balance. Demand letter is also sent at this time.
PLB reason code (WO) overpayment recovery.
http://cms.gov/transmittals/downloads/R6590TN.pdf
RAC 2012
44

Transmittal 47, Interpretive Guidelines for
Hospitals June 5, 2009
www.cms.hhs.gov/transmittals/downloads/R47SOMA.pdf



“All entries in the medical record must be complete. Defined
by: sufficient info to identify the pt; support the dx/condition;
justify the care, treatment, and services; document the course
and results of care, treatment and services and promote
continuity of care among providers.
“All entries must be dated, timed and authenticated, in
written or electronic format, by the person responsible for
providing or evaluating the service provided.”
“All entries must be legible. Orders, progress notes, nursing notes,
or other entries ….. (Also CMS covers in SE1024 MedLearn release)
RAC 2012
45




Provide a legible full signature (a
readable first name and last
name)
Provide a legible first initial and
last name
Write an illegible signature over
a typed or printed name.
Write an illegible signature on
letterhead with information
indicating the identity of the
signer. (EX: a prescription has an
illegible signature but the
letterhead of the prescription
lists three physician names.
Circle the name of the physician
who wrote the prescription.
 Use an illegible signature
accompanied by a signature log
or attestation statement.
 Write initials over a typed or
printed name.
 Write initials not over a typed or
printed name, but accompanied
by a signature log or attestation
statement.
 Neglect to sign a portion of a
handwritten note, but other
entries on the same page in the
same handwriting are signed.
 SEND the LOG WITH AUDIT
MATERIAL.
RAC 2012
46

Heart Failure (MS DRG 291, 292, 293)
Physician documentation must include the ‘type ‘ of CHF in
order to capture this diagnosis as either being a CC or a MCC
condition.

Excisional Debridement (MS DRG 463, 464,
465)
Medical record documentation must support the code
assignment of 86.22 and must meet the definition of
‘excisional debridement.” …involves the surgical removal or
cutting away as opposed to mechanical removal, i.e.
brushing, scrubbing and/or washing.
RAC 2012
47



Hybrid records present extreme challenges in
identifying the skilled care/handoffs of
intensity of service between the care areas.
EMRs tend to present the patient’s history in
a ‘cookie cutter’ concept without pt specific
issues.
Treatment/outcomes/results of ordered
services are often omitted from the
clinical/nursing record.
RAC 2012
48
RAC 2012
49




1850 reporting, 1400
had activity/2000
hospitals
RAC denied $86M, up
from $42 in 3rd Q
Of the $86M, 23% were
appealed, 77% was not
appealed/ 75% (4Q
2011)
Of the 25% that was
appealed, 85% were
overturned in favor of
the providers.




Medically unnecessary
57% of denials, 33%
were short stays
Ave automated : $399
Ave complex : $5281
with a growing amt in
medically unnecessary
Will expand the
tracking of
administrative burden
RAC 2012
50





“Implementation of Recovery Auditing at the
CMS. FY 2010 Report to Congress as
required by 6411 of Affordability Act.
Accuracy rate by the RACs: Low to high:
DCS/98.6 –HDI/ 99.2%
$75 M in overpayments. 82% of all activity
16 M in underpayments. 18% of all activity
Reasons:
◦ Not coded correctly
◦ Not meeting Medicare’s guideline for an inpt
◦ Supporting documentation does not match the order.
RAC 2012
51
CGI has started complex requests for OUTPT services. So far
all outpt have been automated -most MUE problems. (Sept
2010)
 Basic Radiation Dosimetry Calculation - Outpt- CPT 77300
 Comparison will be made in regards to units of Dosimetry
calculations reported in the medical record versus those units
of dosimetry calculation reported on the claim, to establish
whether a difference inn reported units compared to those
documented resulted in an overpayment for CPT 77300.
HDI has issued “minor surgery and other treatment billed as an
inpt stay” Claims billed for minor surgery or other treatment
are identified for medical review based on risk of inpt
improper payment.” (Oct 2010)
 Involve surgery scheduling/surgery director and UR to review
all cases.
RAC 2012
52








June, 2010 Connolly posted new issues relative to
drug /J code accuracy. Tying the J code and the
units/multiplier on the UB.
Paclitaxel
Cetuximab
Paclitaxel protein –bound particles
Tenectplase
Pamidronate disodium
Adenosine
Zoledronic acid (reclast) 1 mg
RAC 2012
53
Summary: Review & Collection Process
1
Automated Review
New
Automated
Review
Issue
Posted to
RAC’s
website
2
RAC makes a
claim
determination
The Collection Process
3
Carrier/
FI/MAC
issues
Remittance
Advice (RA)
to provider
From Cmdr Casey, RN, CMS
N432:
Complex Review
6
New
Complex
Review
Issue
Posted to
RAC’s
Website
“Adjustment
based on a
Recovery
Audit”
9
8
Provider
submits
medical
records
• Provider has 45 + 10
calendar days to
respond
• Providers may
request an extension
• Claim is denied if no
response
RAC clinician
reviews
medical
records;
54
Day 41
Carrier/FI/
MAC
recoups
by offset
• Recoupment
will NOT
occur if:
provider
has paid in
full; or
provider
filed an
appeal BY
day 30
makes a claim
determination
• RAC has 60
calendar days
from receipt of
medical record to
send the Review
Results Letter
5
If no
findings
STOP
RAC 2012
54






Charged to the provider if demand amt is not
paid within 30 days of the letter. 31-41st days of
interest, auto recouped on 41st day.
Charged to the provider if an appeal is filed
within 30 days (normal is 120) to stop the
recoupment.
Paid to the provider if the money was recouped
on the 41st day, appeal filed and overturned.
No interest is paid if the money is given back
voluntarily, even if over turned on appeal.
Interest is each 30 days, not compounded. 11%
Reference: CR7688 /July 12, updates
CR683/Sept 08
RAC 2012
55




HDI and CGI have started sending their ‘New
Issue Validation’ sample letters.
Statement of Work allows sampling of up to
10 claims (in addition the 45 day limit) to
prove a vulnerability with a new issue. Results
will be issued on the findings with data
submitted to the New Issue Board/CMS.
HOT: Share what was requested so potential
new items are know; preventive work.
EX) Readmission within 30 days for AMS.
RAC 2012
56


Document your waste. Recouped for
charging 60 U when only 50 was
documented. Used single use vial, but no
wastage was documented. (pharmacy?
Nursing? Eff 6-10)
Do not use default CPT codes. 99218/initial
day OBS has a MUE of 1. However, some
hospitals are using for OBS hrs in FL 44. If
not required to use G code, leave blank.
RAC 2012
57


MAC/NGS has an LCD (L25820) with document expectations
for drugs and biologicals.
“The medical record must include the following information:
◦
◦
◦
◦
◦
The name of the drug or biological administered
The routing of the administration
The dosage (e.g. mgs, mcgs, cc’s or ICUs)
The duration of the administration
When a portion of the drug or biological is discarded, the medical record
must clearly document the amt administered and the amount wasted or
discarded.”
Policies on how this will be done – as other payers may not
acknowledge the billing of wastage.
RAC 2012
58




Nov 11, 2010's reply from Scott Wakefield, CMS Project
Officer for CGI/ Region B:
"The 60 day timeframe for a RAC to respond to medical
records sent by a provider is a contractual requirement for
the RAC National Program, therefore, it is possible that noncompliance by the RAC may result in assessment of a lower
score in their annual performance appraisal. This cumulative
results of this appraisal impacts CMS's determination of
whether to extend the incumbent RAC's contract for an
additional year. I recommend you contact the RAC directly
and inquire about follow up with the remaining records. I
have copied certain CGI federal staff on this email and will
request that they follow up with me."
No direct penalty, no auto closing/approved of case.
UPDATE with new SOW: No payment to the RAC (9-11)
RAC 2012
59


19 inpts ADRs in 6 week period
All 1 day or very short stay on inpt surgeries
Acute
appy- day
CVA/TIA- Hypokalemia/ Total
1 day
Acute Renal
shoulder –
failure – 2
1 day
days
Hypotensiv
e
Pt/readmit
GI bleed2 days
Carbon
monoxide1
Pneumoni Seizures/PNA
a-2 days -expired-1
day
Hemo cath
placement1
Total knee
replacemen
ts – 2 days
Obstructi
vehepatis
istransferre
d
Panyctopeni
a – 1 day
(?comfort
care)
Below knee
Breast
amputation-1 Reductionday
1 day
Non-union
malleolus
(surgery) -1
day
RAC 2012
60


Medically unlikely edits have resulted in
charge capture errors. Many MUEs are
unknown to the providers. (Automated)
Examples:
◦ 4 ST/92507 treated as per 15 instead of per
encounter. Only 1 is allowed
◦ 4 EKG/93005 MUE is 3 in a given 24 hr outpt day.
Would have to appeal that the 4th one was medically
necessary to the uniqueness of the pt’s needs.
RAC 2012
61




No auto crossovers/Medigap for pt portion. All
pt portions are due to the pt or their
supplement.
MAC can override the DRG that the RAC
assigned. (Connolly/Cahaba) Which one is
appealed?
Site prepares record so a “kindergartener’ can
find the pertinent info prior to submission.
(AK)
Upon receipt of the ADR, a letter is sent to the
impacted physicians informing them of the
request. Generates excellent conversation.. (NJ
hospital)
RAC 2012
62
Underpayments are occurring too.
 EX) IA hospital billed transfer DRG – pt was to
have had HH or SNF care post inpt. Facility
was paid a per diem vs DRG.
RAC identified the underpayment as there
were no claims from HH or SNF for the post
care. Repaid full DRG for 7 accounts,
$13,000.
Better practice idea: D/C planning verifies in
the 3 day hold that the pt had above
services. Revised discharge disposition.

RAC 2012
63




Why us? There does not appear to be any patterns to the
requests. They are one of 3 hospitals in the area. Only one to be
hit with audits.
Max # of records per 45 days: 48. Have had 143 in last 12 mon
High DRG: 69/Transient Ischemia, 312/syncope & collapse,
101/seizures w/o MCC
Complex:
◦ Sept, 2010 – 1st medically necessary audits. 48 had both DRG and MN. All 48
had 0-2 day LOS
◦ Appears Connolly is targeting the 2nd diagnosis that make up the CC or MCC
◦ RAC Target DRGs: 981/982/983 Extensive & non-extensive OR procedures
unrelated to principle Dx. Also 330/sm & lg bowel procedures
237/major cardiovascular w/MCC; 242/permanent cardiac pacemaker implant
w/MCC.
4 highest MDCs: Respiratory, circulatory, digestive and Musculoskeletal &
connective
RAC 2012
64

Automated
◦ MUEs – lab/80053 comprehensive metabolic profile & 83880 BNP
◦ CPT 62311/lumbar injection. MUE only looks for the correct modifier
w/no considerations for distinct locations.
QUIRKY:
◦ MAC assigns the overpayment amt for the demand letter. 1 demand letter
where the demand was more than submitted.
◦ On at least 2 claims, the MAC approved a RAC denial and gave the RAC
permission to send out a demand letter. The RAC failed to do so. The MAC
assumed we had not responded to a letter so they went ahead and recouped
the payment.
Update 10-11
44 complex requested each 45 days. 26% of all claims submitted results in
denials. Each results letter is evaluated to determine to appeal or not. Overall,
15% denial rate. Considerable focus on education to prevent future denials.
RAC 2012
65



If a provider performs a self audit, how should they notify the
RAC?
A: If a provider does a self audit and identifies improper
payment, the provider should report the improper payments to
the appropriate MAC, FI or carrier. The exact information
necessary for the self referral can be determined by contacting
your Medicare claims processing contractor.
There are two types of self audits: 1) Commonly called a voluntary
refund and is claim based. If the required claim information is included
along with the amt of the improper payment, the claim will be adjusted.
The RAC will be aware of the adjustment, but the refund does not
preclude future review. 2) Involves extrapolation. If extrapolation is
used, the claim processing contractor will review the case file to
determine if it is acceptable. The MAC can accept or deny the
extrapolation for the issue identified by the provider. If the claim MAC
accepts the extrapolation, these claims will be excluded from the RAC
review.
RAC 2012
66



Initial claim submission of Part B on a Part A
claim is allowed. No Obs, no surgery, no
anesthesia, no recovery. Ancillary only.
Rebilling of a denied inpt claim within the
timely rebilling requirements is a Part B on a
Part A claim. Bill type 12x. Ancillary only.
HOPE: AHA continues to champion trying to
get CMS to allow bill type 131/regular outpt
for a rebilled denied claim.
RAC 2012
67

These revenue codes/department charges are
billable on a Part B claim of a denied Part A
service. 12x (Benefit Policy Manual, Chpt 6, section 10; Claims
billing manual 100-04, Chpt 4, section 240)

27x/supplies; 30x/lab;32x/imaging; 331 & 335/chemo;
333/Radiation therapy; 34x/nuc med; 35x/CT; 379/anesthesia;
401/dx mammo; 402/ultrasound;403/screening mammo;
404/PET; 42x/PT; 43x/OT; 44x/ST; 46x/pulmonary; 48x/cardio,
cath lab, cardiac stress test; 540-45/ambulance;
61x/MRI;634/Epo under 10,000 U; 635/Epo over 10,000
W;636/pharmacy;730-1/EKG & ECG tele;732/tele;739/EKG
cardio lab;74x/EEG;77x/Vaccination adm;790/litho;920/other
dx services; 921/vascular lab; 922/EMG;923/pap
smear;929/invitro fertilization; 985/non-invasive physician. NO
Surgery!
RAC 2012
68





Can I rebill or must I file an appeal?
Call with CMS/HDI/WPS J5, a MAC 7-8-10
If RAC has identified a MUE due to a charge
capture error and there was an accurate CPT
that should have been used, an appeal &
corrected UB must be filed to get the money for
the corrected CPT.
If the facility did data mining and found that
the same issue had occurred on other claims, a
corrected claim should be submitted.
Discuss with the MAC prior to either to ensure
it is done correctly.
RAC 2012
69

If an inpt/outpt is denied and the facility
determines a misunderstanding of a Medicare
regulation occurred, to get the correct CPT
code/corrected amt, the facility must appeal.
Additionally, the RAC team should immediately
discuss the need to continue to data mine
similar issues.
Internal cost as manual rebill.
Only ancillary services can be rebilled
Pt had refund for inpt deductable; now will owe outpt coinsurance.
Perception to public
Real C A S H
Track and trend any recoupments with rebills separate from recoupments with
100% absorbed losses
◦ Timeline for rebills must be followed
◦
◦
◦
◦
◦
◦
RAC 2012
70
•
•
•
•
•
If the inpt is denied, the pt (and Medigap supplements)
will be informed they don’t owe the inpt deductible.
Refund to pt and/or supplement or auto recoupment.
If the facility determines they would like to do a
corrected claim submission once a decision is made not
to appeal – the pt will receive notice they owe a new
outpt deductible/coinsurance.
If the outpt claim is denied payment, the pt will be
informed they don’t owe the outpt portion.
HINT: Develop scripts for the PFS staff to explain.
NOTE –all activity/recoupments can go back 3 years
beginning with 10-1-07 PD dates rolling forward.
RAC 2012
71





Dear pt
As part of ABC hospital’s commitment to compliance, we are
continuously auditing to ensure accuracy and adherence to
the Medicare regulations.
On (date), Medicare and ABC hospital had a dispute regarding
your (type of service). Medicare has determined to take back
the payment and therefore, we will be refunding your
payment of $ (or indicate if the supplemental insurance will
be refunded.)
If you have any questions, please call our Medicare specialist,
Susan Jones, at 1 -800-happy hospital. We apologize for any
confusion this may have caused.
Thank you for allowing ABC hospital to serve your health care
needs.
RAC 2012
72
June 26, 2009/CMS Website
 CMS reversed earlier decision to AUTO
recoupment SNF payment if the hospital is
denied/recouped its 3 day qualifying stay.
 If the hospital is recouped for any activity,
Part B/physician will be evaluated, but not
auto recouped.
 Will look but not auto recoup in both.
RAC 2012
73
Value Added
Section
RAC 2012
74




New issue: Inpt Admissions without a
Physician’s Inpt Admit Order.
Description: Admissions to the inpt setting
require a physician’s order in order to
qualify and be paid as an inpt stay.
Inpt hospital
10-01-07 open
Reference info: CMS pub 100-02, Chpt 1,
section 10 and pub 100-4 Chpt 4, section
10 and 40.2.2
RAC 2012
75

Addition documentation letter received read:

“Good Cause for Issue: Chronic Obstructive Pulmonary

Disease DRG 88 MS-DRG 190, 191 (Medical Necessity Review
and MS-DRG Validation). During the course of the DRG
validation, the RAC will also review the record for inpt
admission order.
The documentation is being requested because COPD is one
of CMS’s top volume DRGs. Therefore, DRG 88, currently
MS-DRG 190 and 191 was selected to determine if the
principle and secondary diagnoses were assigned
inappropriately resulting in overpayments to the hospitals.
An analysis of your billing data indicates that a potential
aberrant billing practice may exist for these MS-DRGs.”
RAC 2012
76



Dec 9, 2010 letter from Region A/DCS outlining
rationale for why they were requesting medical records
for numerous DRGs. They also gave a great outline of
inpt vs obs.
“Inpt care rather than OBS is required only if the pt’s medical
condition, safety or health would be significantly and directly
threatened if care was provided in a less intensive setting. A
patient must demonstrate signs and/or symptoms severe
enough to warrant the need for medical care and must receive
services of such intensity that they can be furnished safely and
effectively only on an inpt basis.”
When auditing for ‘what does severity and intensity look
like- look for the above issues to be addressed in the
physicain admit note/order and the nursing bedside
documentation.
RAC 2012
77


1st MN request, 90 records, DX listed below for the 6 MN new
issues
Had DRG, MN and inpt accuracy listed on all
COPD
Cardiac
Arrhythmia
Excisional
debridement
Heart failure and
shock
Renal failure
Extensive OR
procedure
unrelated to
principal Dx
Disease/disorder
of the respiratory
system
Kidney & UTI
Espohagitis/
gastronenteritis
Aneurysm repair
Coronary bypass
w/PTCA
Tracheostomy
Perc Cardiovasc
procedures
w/stent
GI Disorders
Other circulatory
system dx
Other vascular dx
Syncope and
collapse
Red blood cell
disorders
Atheroscleroris
with MCC
Nervous system
disorders
RAC 2012
78




Rural Critical Access hospital. Ave Census 2
HDI “short stay change notification”. “After our
review, it is our determination that the claims
listed should have been outpt OBS vs inpt.” 818-10
Direct admit from a clinic. HDI findings:
“Pt chief complaint was hypoxia. The pt presented to
ED for acute bronchitis, severe COPD – admitted as an
inpt. Past medical hx and the pre-existing conditions
are stable. The medical records did not document preexisting medical conditions or extenuating
circumstances that make the acute inpt admission
medically necessary. The med record document
services that could be provided as an outpt service.”
RAC 2012
79

“RAC will review documentation to validate the medical necessity
of short stay, uncomplicated admissions of MS DRG (XXX).
Medicare only pays for inpatient hospital services that are
medically necessary for the setting billed and that are coded
correctly. Medical documentation will be reviewed to determine
that the services were medically necessary and were billed
correctly.”
“RACs will also review documentation for DRG Validation
requiring that diagnostic and procedural information and the
discharge status of the beneficiary, as coded and reported by the
hospital on its claim, matches both the attending physician
description and the information contained in the beneficiary’s
medical record. Reviewers will validate for MS-DRG, principal
diagnosis, secondary diagnoses and procedures affecting or
potential affecting the DRG.” (Aug 2010)
RAC 2012
80



A) When validating all information prior to submission, be sure to
specifically address any issues outlined in the letter. This applies to
appeal or discussion periods or any communication. Simply stating that
our patient was very sick -although accurate - the audit is auditing
billed services (as reflected on the UB and 1500 forms) are accurately
reflected in the medical record.
B) Do you have a clinical documentation improvement
program? EXPAND It beyond typical physician documentation to
clarify DRG issues to SEVERITY of illness/docs and INTENSITY of
services /nursing. Grow the documentation to support the level
of care billed..
C) Track and trend your own vulnerabilities thru the validation prior to
submission process. The opportunities are endless for our records to be
improved -including revising EMR documentation. Patterns of risk are
excellent tools for ongoing education , process changes, form
development and overall cohesive pt care. Charting by exception is the
worst type of charting to show intensity of care. Tell the pt's story and
outline the interventions, results, handoffs, etc that occurred.
RAC 2012
81


D) ALWAYS print off the EMR (even if you have an release of
information vendor, especially if you have a hydrid record ) and
closely audit the handoffs between the departments - closely
looking for intensity of care, clarity in interventions (what we did
about results, tele strips) and how the pt's condition continued
to warrant an acute level of care.
E) Major focus on nursing's canned documentation with
EMRs.. Number the pages; create a cover letter that CLEARLY
shows the doc's order for inpt with WHY he wanted them in an
acute care setting with a defined course of treatment plus
highlights of test results, intensity of the condition, etc. The
lack of this type of validation can easily result in a fragmented
record with very difficult severity and intensity of care
identified. (HOT SPOT: ER = paper; floor nursing = electronic.
How many admits come thru the ER? Huge area of audit and
focused documentation improvement.)
RAC 2012
82
Which option
should I use?
Discussion
Period
Rebuttal
Redetermination
The discussion
period offers the
opportunity to
provide
additional
information to
the RAC to
indicate why
recoupment
should be
initiated. It also
offers the RAC
opportunity to
explain the
rationale for the
overpayment
decision.
A rebuttal should be
submitted only on
rare occasions of
extreme financial
hardship. The
rebuttal process
allows the provider
the opportunity to
provide a statement
and accompanying
evidence indicating
why the overpayment
would cause extreme
financial hardship.
A rebuttal is not
intended to review
supporting medical
documentation. A
rebuttal should not
duplicate the
redetermination
RAC 2012
process.
A
redetermination
is the first level
of appeal. A
provider may
request a
redetermination
when they are
dissatisfied with
the overpayment
decision. A
redetermination
must be
submitted
within 30 days
to prevent offset
on the 41st day.
83
Discussion
period
Rebuttal
Redetermination
Who do I
Contract
RAC
Contractor/MAC
Contractor/MAC
Timeframe
Day 1-40
Day 1-15
Day 1-120; must
be submitted
within 120 days of
demand letter. To
prevent offset on
day 41; file within
30 days but
interest will accrue
(Transmittal 141)
Timeframe begins
Automated
review-upon
demand letter:
Complex-upon
results letter
Date of demand
letter
Upon receipt of
demand letter
Timeframe ends
Day 40 (offset
begins on day 41)
Day 15
Day 120
RAC 2012
84
Audit Results and
Better Practice Ideas
To Reduce Risk
RAC 2012
85




“HDI has signed a 5 year license with Milliman Care
Guidelines. HCI will use the care guidelines
content and software to review Medicare claims.
HDI will use the annually updated evidence based
care guidelines products.
The Care Guidelines promote healthcare quality by
providing clinical guidelines based on the best
available clinical evidence.”
CMS does not mandate or endorse any specific
guidelines or criteria for utilization review.”
Feb 25, 2009 “Evidence-based care guidelines will be used to combat waste in Medicare
program.”
RAC 2012
86


An inpatient is a person who has been admitted to a hospital for bed
occupancy for purposes of receiving inpatient hospital services.
Generally, a patient is considered an inpatient if formally admitted as
inpatient with the expectation that he or she will remain at least
overnight and occupy a bed even though it later develops that the
patient can be discharged or transferred to another hospital and not
actually use a hospital bed overnight.”
“However, the decision to admit a patient is a complex medical
judgment which can be made only after the physician has considered a
number of factors, including the patient's medical history and current
medical needs, the types of facilities available to inpatients and to
outpatients, the hospital's by-laws and admissions policies, and the
relative appropriateness of treatment in each setting. Factors to be
considered when making the decision to admit include such things as:
– The severity of the signs and symptoms exhibited by the patient;
– The medical predictability of something adverse happening to the
patient…”
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Trailblazer/MAC Jurisdiction 4, 8-30-10 “Inappropriate
Hospital Admission vs Outpt Observation”
Medicare requirements that the inpt admission begins when
the admission order is written. Additionally, all physician
orders must have a date and a legible signature.
Physician’s decision to treat the pt as an outpt or inpt are
reflected in the physician’s orders. The pt’s condition,
history and current dx test results, along with the physician’s
medical judgment, availability of treatment modalities and
hospital admission policies should be considered when
making a decision to provide inpt level of care. If a physician
determines additional information is making a medical
decision for inpt admission, the physician may elect to place
in OBS outpt status.
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Scenario 1
An inpt claim is submitted for medical review
◦ The claim is without a written and signed physician order for admission
◦ The documentation is without an admit note describing the reason for
admission to an inpt level of care/LOC
◦ The services rendered could have been rendered in an outpt setting
◦ The screening tool indicates the intensity of services and the severity of
illness of the pt’s condition as documented did not support the medical
necessity for inpt LOC
◦ Medical review decision: Denied because documentation does not support
the medical necessity for an acute level of care
◦ IF THE PATIENT’S CONDITION REQUIRES INPT ADMISSION, the physician
needs to document an inpt admission order with a progress note
describing the medical decision for the inpt admission and the intended
treatment plan to address the patient’s condition.
◦ Internet Only Medicare Manual (IOM) Pub 100-04, Medicare Claims
Processing Manual; chapter 1, section 50.3; chapter 3, section 40.2.2.k
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Variance rate: 40%
Common findings:
◦ UR/physician dialogue may indicate inpt, but the
documentation in the admission order (or subsequent
physician documentation) is not sufficient to address the
severity of the pt’s condition for today’s condition that
warrants an inpt acute level of care.
◦ “Meets or doesn’t meet Interqual” does not make an inpt.
Medicare’s definition is not well known.
◦ Weakness in EMRs that do not address the ‘uniqueness’ of
the pt’s care and intensity of the service that is being
performed. (Nursing documentation- no narrative to
support electronic-no ability to expand on the uniqueness
of the pt’s story.)
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Problematic diagnoses and other risk areas:
◦ Rule out – anything! If a physician is not clear as to the
reason for admit/undetermined dx or course of treatment,
place in OBS, aggressively work up the pt and rule in= inpt;
rule out= discharge safely. (Exceptions do exist)
◦ Using a non-treating physician to confirm inpt status does
not replace or supplement the attending/treating
physician’s documentation.
◦ Conversations to support “admitting to inpt” is rarely
actually documented in the record.
◦ H&Ps and D/C summaries are not consistently present.
◦ Normal OUTPT Surgeries being ordered as inpt
surgeries…not on the inpt only list. UR needs to work
closely with surgery scheduling.
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Definite misunderstanding of what OBS is.
Viewed as a time frame rather than a pt’s
condition. (Miracle 23 hr cures = discharge
or Monday am quarterbacking to ‘fix
weekend.”)
Billable hrs vs hrs in a bed
Audit three types of OBS:
◦ ER to OBS – saw provider onsite
◦ Post procedure to recovery to OBS
◦ Direct from a provider or SNF to a bed
Highmark/MAC , new inpt/OBS
www.highmarkmedicareservices.com/bulletins/parta/newsrooms/news09
302010
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•
Variance rate two fold:
– To be an inpt
– To remain an inpt
•
40%
60%
Audit focus:
– Medically appropriate to be an inpt
– Medically appropriate to remain an inpt for all 3
days.
– Severity of illness/1st day; intensity of service/all 3
midnights.
– Common weakness: Social admits= TOUGH
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•
•
•
•
•
When submitting a request for an appeal, you have
different options.
Submit in writing or via fax. When utilizing the fax,
there is no need to follow up with a hard copy of
the documentation.
Submit your request only one time, utilizing only
one method.
Duplicate submissions or following up with
hardcopy may delay your appeal.
If you are bringing attention to a specific item you
are faxing, please circle or indicate by asterisk, as
highlights do not appear when the fax Is received.
Aug 20, 2010
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Begin charge capture/charge reconciliation
audits. Department head ownership!
Begin ongoing reimbursement education with
audits of billed services against
documentation.
Focus on identified weaknesses from
benchmark audits, RAC automated results
and complex reviews – with corrective action
plans.
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Joint audits. Physicians and providers audit the
inpt, OBS and 3 day SNF qualifying stay to learn
together.
Education on Pt Status. Focus on the ER to address
the majority of the after hours ‘problem’ admits.
Identify physician champions. Patterns can be
identified with education to help prevent repeat
problems.
Create pre-printed order forms/documentation
forms. Allows for a standard format for all
caregivers.
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•
•
•
•
•
Region A (DCS)
–
www.dcsrac.com
–
info@dcsrac.com
–
1-866-201-0580
–
CMS RAC Contact: Ebony.Brandon@CMS.hhs.gov
Region B (CGI)
–
http://racb.cgi.com
–
racb@cgi.com
–
1-877-316-7222
–
CMS RAC Contact: Scott.Wakefield@CMS.hhs.gov
Region C (Connolly)
–
www.connollyhealthcare.com/RAC
–
RACinfo@connollyhealthcare.com
–
1-866-360-2507
–
CMS RAC Contact: Olive Taylor, CMS.hhs.gov
Region D (HDI)
–
http://racinfo.healthdatainsights.com
–
racinfor@emailhdi.com
–
1-866-590-5598 Part A
–
1-866-376-2319 Part B
–
CMS RAC Contact: Brian. Elza@CMS.hhs.gov
CMS assigns a project officer to each RAC. Use if
abuse of the SOW or other issues are occurring.
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•
•
•
•
•
•
•
New issues will be posted, RAC specific
There is a CMS/project officer assigned to each
RAC
New issues are being added/some are being
taken off.
Region A-DCS Info@dcsrac.com 866 201 0580
Region B-CGI RACB@cgi.com 877 316 7222
Region C-Connolly
www.connollyhealthcare.com/RAC; RAC
info@connollyhealthcare.com 8663602507
Region D-HDI racinfo@emailhdi.com 866590
5598
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Day Egusquiza, President
AR Systems, Inc
Box 2521
Twin Falls, Id 83303
208 423 9036
daylee1@mindspring.com
Thanks for joining us!
Free info line available.
Plus our training website: www.healthcareseminar.com
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