The anticipated blackout period for the Recovery Audit Contractor (RAC) for Kentucky has been delayed. Highmark Medicare Services, Inc. (HMS) was awarded the Medicare Administrative Contract (MAC) for combined Part A/Part B Medicare services in Jurisdiction 15 which is comprised of Kentucky and Ohio. However, two protests were filed which have delayed the transition from the current fiscal intermediaries to Highmark. Providers will eventually receive notification of the timeline for the transition once it has been determined. The ninety day blackout period for the RAC will be defined once the transition timeline is set. For now, all providers should anticipate the RACs are conducting business as usual and proceeding with their audit agenda.
CGI Federal recently posted new approved issues on their RAC website. The announcement is further indication that 2010 will be a busy year for providers; particularly for complex reviews involving MS-DRG coding and DRG validation. There are over thirty-eight issues that deal specifically with MS-DRG and DRG validation. Medical necessity reviews are specifically excluded from review at this time. With auditors beginning the process of conducting more advanced audits, it is anticipated that RACs will attempt to find evidence of “upcoding”. It is very resource-intensive to respond to complex reviews. Providers have only forty-five days to respond to the RAC notification. In some instances, the information they are requesting may go back to October 1, 2007 so the medical records may be in storage, some may be on paper, and some may be electronic. The complex review will require many more man-hours from providers than an automated review.
Dean Dorton Ford recommends that providers visit the CGI website frequently and prepare for the complex reviews that are anticipated for 2010. Here are a few simple measures to help you prepare and reduce your risk in 2010:
- Review all approved issues for your region
- Conduct internal audits for coding and DRG validation on the approved issues list
- Physicians documentation remains key to successful for appeals – conduct documentation audits and education as necessary based on internal review and audit findings
In addition, the Office of the Inspector General (OIG) released a report in February of 2010 on the outcomes of the Recovery Audit Contractors’ Fraud Referrals. It simply stated that during the Demonstration project, RACs identified over $1 billion in improper payments, yet only referred two cases of fraud to the OIG. RACs do not receive any contingency fees for the cases they refer so there may be some disincentive for RACs to refer cases of potential fraud to the OIG. RACs are required to report any cases of potential fraud that they identify; however, they must be able to identify fraud to refer it. CMS is going to provide mandatory training on the identification and referral of fraud. Also, the OIG recommends they implement a database system to track fraud referrals that arise from the fraud referrals from the RACs.
For more information please contact:
Pam Hicks
phicks@ddfky.com
859.425.7636


