Jurisdiction A’s RAC, Performant Recovery, is currently auditing post-pay claims on respiratory assist devices (RADs) and vacuum erection devices (VEDs). 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 three years prior to the ADR date are not subject to this review.
The RAC website described the issue for RADs as, “Potential incorrect billing may have occurred for respiratory assist devices (RAD) that did not meet the medical necessity requirements as described in the NHIC Local Coverage Determinations L33800 and L11504.”
The issue for VEDs was described as, “Vacuum erection devices were paid under the DME Prosthetic benefit, which stipulates the device must be used to replace all or part of an internal body organ. Local Coverage Determinations in effect through June 30, 2015, describe medical necessity criteria. As of July 1, 2015, vacuum erection devises were statutorily excluded from coverage. Potential incorrect billing exists when the documentation does not support the Medicare criteria for coverage.”
In August of 2015, Performant announced that they were conducting complex reviews of ventilators and parenteral nutrition claims.