These MRI audits are the infamous “Semi-Automated Reviews” that first showed up this past spring. Here’s the CMS FAQ — basically this appears to be a way for the RACs to circumvent the ADR limits, which were recently changed, but only for the smaller providers. Meanwhile, these ADRs coming from semi-automated reviews have no limits, and seem to have little valid logic.
It was reported to us that CMS views semi-automated reviews as a way for providers to have a “discussion period” for what would otherwise be purely a black-and-white automated denial with immediate recoupment. The logic is that the provider can review the denial, then has 45 days to discuss it with the RAC, before the recoupment occurs. While this might seem to favor the provider, the Law of Unintended Consequences is running wild.
One hospital we spoke to today has so far received requests for 76 records involving MRI claims. Their 45-day limit is 150 records, but they have already received those ADRs, getting hit with the maximum on every 45-day cycle. We spoke to some facilities, as well, all with similar experiences — a hospital system with 10 facilities received over 300 ADRs just this week; and a university hospital received over 100 denials (straight denials, no ADRs to go with them) in the past two weeks.
Many providers wisely review the records for automated denials to determine whether they might wish to fight the denial and automatic recoupment. We are told that a very large percentage of these denials make no sense. For example, the denials claim that the MRIs were billed for patients who had cardiac devices implanted — cardiac devices seem to be an almost exclusive choice for the denials. Records reviews by the provider, however, often indicates either no devices that they can find, or something as small as a stent. We were also told of a denial that was made based on coding for a temporary pacemaker — HDI’s auditors did not apparently understand the difference between a temporary and permanent pacemaker.
Ernie de los Santos is the Founder of the California-based blog network, The RAC Shadow, where he maintains a free database of all RAC Approved Issues.