Ernie De Los Santos
These MRI audits are the infamous “Semi-Automated Reviews” that first showed up this past spring. The facts appear to be a way for the RACs to circumvent the ADR limits, which were recently changed, but only for the smaller providers.
Recovery Audit Contractors (RACs) have identified $365.8 million in improper payments made to Medicare providers from October 2009 through March 2011. The payments were issued as long ago as three years prior to the dates on which they were identified by the RACs, marking the limit of the lookback period in which contractors were allowed to search.
Connolly Healthcare has posted a new approved issue calling for DRG Validation review of 309 MS-DRGs and/or 141 ICD-9 diagnosis codes.
CMS has apparently determined that facilities with DRG payments in excess of $100 million during the last fiscal year have the ability to address a larger number of RAC additional documentation requests.
Connolly Healthcare, the Recovery Audit Contractor (RAC) for Region C posted 77 new issues and DCS, the RAC for Region A posted seven new issues, continuing the pattern that healthcare providers have come to expect from all four RACs - postings that present confusing, incomplete and oftentimes contradictory information.
The RACs officially rescinded some reviews in the past few weeks, even after having completed complex reviews including the issuance of denial letters to the providers for the claims reviewed.
Connolly Healthcare, the Recovery Audit Contractor (RAC) for 17 states, posted 35 new issues and removed four older issues on its "approved issues" Web page last week. The postings continued a pattern of confusing and incomplete information that healthcare providers have come to expect from the four RACs during recent months.
DCS, the CMS Recovery Audit Contractor (RAC) for Region A, recently posted two new issues, including DRG validations for nervous system procedures and musculoskeletal fractures. Neither of these issues, however, includes medical necessity review at this time.
Connolly Healthcare posted approvals Friday for the review of medical necessity for the same 29 MS-DRGs already cited earlier this month by two other Recovery Audit Contractors (RACs).
Health Data Insights (HDI), the CMS Recovery Audit Contractor (RAC) for Region D, has posted approvals for the review of both medical necessity and DRG Validation for previously approved and listed issues including 29 DRGs, effective Aug. 16, 2010.