Barbara Vandegrift is a senior healthcare consultant with Medical Learning, Inc. (MedLearn), St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that will equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.
Barbara Vandegrift
A new and informative resource is available for providers on the web site of the Centers for Medicare & Medicaid Services (CMS).
Medical records are, of course, at the core of every Recovery Audit Contractor (RAC) complex review. It's up to physicians and other providers to document the information needed to prove medical necessity and, ultimately, for hospitals to receive proper payments for services rendered.
Cardiac pacemaker implantations (DRG 116) made the headlines in the first-ever Medicare Quarterly Provider Compliance Newsletter (issued by the Centers for Medicare & Medicaid Services [CMS] just this month).
Many, if not most, claims are denied because they did not meet medical necessity. If you haven't discovered this yet, chances are you will since Recovery Audit Contractors (RACs) are now reviewing hospital claims for medical necessity.
Although Recovery Audit Contractors (RACs) are not currently evaluating facility evaluation and management (E&M) services, it may not be long before they do.
How are hospitals being affected by the Recovery Audit Contractor (RAC) program? That's a question that the American Hospital Association (AHA) wanted to answer in response to "a lack of data and information" from the Centers for Medicare & Medicaid Services (CMS).
The new healthcare reform law-officially known as the Patient Protection and Affordable Care Act of 2010 (PPACA)-brings with it a new deadline of 60 days to report and return overpayments to the appropriate Medicare and Medicaid contractors.
The primary goal for CMS must be to ensure that corrective actions are in place so that improper payments can be reduced, says GAO.
Clinical and administrative staff at many organizations are struggling with the issue of what "medically necessary" really means.
Medically unnecessary services topped the list of claim errors in the latest comprehensive error rate testing (CERT) report compiled in November 2009 and released last month by the Centers for Medicare & Medicaid Services.