Connolly Review Results Letters Arrive Soon After Records Submitted
Word to the wise: Make SURE you have a process in place to check ALL (Medicare, at least) claims that go out your door to be paid, to insure that a clearly worded, appropriate Physician Order exists in the medical record.
If you do NOT insure that the order exists, you are risking the entire reimbursement. And if CMS decides that a pattern of this type of error is in your facility or practice… you are risking FAR more than that reimbursement.
Before I get to the subject of the headline, let me review what else was going on, recently.
Seven New Issues Posted
Last week was a pretty quiet week, which almost no activity by any of the RACs, except for a few additions by Connolly and HDI, on Friday, September 17. Connolly added 20 new DRG Validations, listed in five of six new (yes, really NEW) issues.
HDI added Part A Services delivered during a Hospice period.
| 1 | Hospice Related Services – A |
But these “new” issues are not all that happened…
Many Edits Made
Over the past couple of weeks, there have been many edits made to existing posts on all four of the RAC sites.
For example, many posted issues for Region A, DCS, actually removed some states from some of their approved issues. You might want to check the list, especially if you are in Vermont, New Hampshire or Maine. (Vermont was dropped from 14 issues, New Hampshire from 12, and Maine from less than that.)
Acute readmissions have been a recognized target for RACs for some time. There was an interesting edit made to the issue as posted on Region D, HDI’s site. Previously, the issue would deny for same day acute re-admissions for the same DRG with no B4 codes on the second claim. Now, it denies for no B4 or 42 Condition Codes on the second claim.
Another edit made in Region D: under the DRG Validation issue for Nervous System Disorders, MSDRGs 075 and 076 were specifically removed from the approved DRG list. Now, I caution everyone, be careful to not transpose those numbers – in the same issue are the approvals for Medical Necessity and DRG Validation for MSDRGs 057 and 056. I warn you because I myself have more than once looked at the list and been puzzled by it, when I kept thinking that the wrong ones were removed.
Denials for Lack of Physician Order
Despite the lack of activity on the lists themselves, the RACs have been very busy, sending out review results letters and denials. We have seen in Region C the first denials to come thru for a lack of or improper physician orders in a medical record. The types of claims being denied are both inpatient and outpatient. I can give you two examples that happen to be short stays.
An outpatient claim, where the patient wound up staying for 3 days. At some point, the patient’s status was changed to inpatient, which would have been appropriate (I’m told by the provider), except for one thing: in the documentation, there is a Nurse’s note, changing the patient status to inpatient, but there is nothing at all in the record that indicates that a physician ever approved or ordered this change. The claim was therefore denied, and the provider has no chance on appeal, because the physician’s order simply does not exist.
An inpatient claim, a 1-day stay: the patient was admitted to inpatient, even with just an 8-hour stay. I was told that the services were, in fact, inpatient services, and could have survived audit for inpatient status. Well, it could have survived, except for one thing: no physician order appears in the record to admit to patient to anything. Once again, the claim was denied; and again, there is no chance to appeal, since the order simply does not exist in the record.
Want to know the scary thing? Those claims were very easy to deny, they are not “worthy” of appeal, and the provider told me that the number of records requested was very few, compared to the limits that the RAC could ask for. In other words, the RAC knew exactly which records to ask for, and they were right on the money. It seems like this is the proverbial “Easy Money” for the RAC.
Like I said, “Word…”
Why Did They Wait?
But if this is so easy, then why wasn’t the RAC doing this more, before now? My opinion is that the RACs have been waiting for at least some of the Medical Necessity issues to be released, so that they don’t have to ask for the records again, or so that they can have all their weapons loaded before they begin the battle in earnest. I think it is because the RACs are private companies, who actually care about efficiency. In the private sector, efficiency means more profits, and this makes private sector companies much better at this kind of work than many government agencies, who don’t have to worry about such “bourgeois” concerns as “profits.”
So What’s the “Word”?
Providers need to insure they have a reliable process in place to check documentation for physician orders before any claim is filed.
Which ones should they check? Only the ones they intend to send out the door. The RACs are willing to do this job for just nine percent of the claim (in Connolly’s case, anyway).
A provider, then, should be willing to do this for slightly more than that… say, 100 percent of the claim.
So I guess I’ll say that’s the “Word”: 100%.
That’s what is at stake, and that’s what providers should check.
The RAC contracted for the southern and southeastern states, Connolly Healthcare, continues to post new automated issues concerning dose-versus-units-billed, further proving that injections and infusions is a major target for RAC review, and a continuing concern for provider reimbursement, especially for physicians and outpatient settings.
In the continuing posting of issues, the RAC contracted for the upper midwestern states, CGI Federal, has now joined Connolly Healthcare in its posting of an issue that can possibly recoup all Medicare Part A charges for an inpatient claim, and still not even touch the dreaded issue of Medical Necessity.
recovery audit contractor
