Jurisdiction A’s RAC, Performant Recovery, is currently auditing post-pay claims on parenteral nutrition and ventilators. States that are affected by this review include: Connecticut, District of Columbia, Delaware, Massachusetts, Maryland, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.
The review for both items will be complex, which means the RAC will be asking for medical records on randomly selected claims. Any claims that have a “claim paid date” over 3 years prior to the ADR date are not subject to this review. The RAC website described the issue for ventilators as, “potential incorrect billing occurred when claims for ventilators were billed without an indication supporting the coverage and/or medical necessity guidelines outlined in the Medicare National Coverage Determinations Manual (NCD), §280.1, and the “Correct Coding and Coverage of Ventilators” Joint DME MAC Publication, including when ventilator codes are incorrectly billed for CPAP- or bi-level PAP-only use.”