RAC AUDIT ALERT

By: Wayne van Halem, President

Well, the RAC is back. We knew it was coming, but what we didn’t know – until now – is where they will begin focusing their audit efforts. In the last couple of weeks, the new national DMEPOS and home health and hospice RAC, Performant Recovery, announced what they will be reviewing.

For our home health and hospice clients, there are no issues identified yet. We don’t expect it to stay that way, but nothing has been published yet. Unfortunately for our DMEPOS clients, we can’t say the same. There have been seven issues identified for review. This includes four complex reviews and three automated reviews.

As a brief reminder, an automated review means there is no human interaction. It is an edit in the system that is run and overpayment demand letter generated. The automated reviews announced are:

Nebulizers: Claim with diagnosis codes that are not supported for coverage in the LCD will be recouped.

Inpatient claims: This is not a new issue and not surprising, but the RAC will compare DMEPOS claim data with Part A claim data and recoup any claims paid while the patient was in an inpatient facility. A complex review is much more comprehensive and involves the RAC requesting documentation and performing a complete review. They have identified the following codes for complex review and the reason for it:

High frequency chest wall oscillation – Potential incorrect billing occurred when claims for high frequency chest wall oscillation devices were billed without an indication supporting medical necessity as described in the Nationwide Local Coverage Determination (LCD) L33785 and prior MAC LCDs L27042, L12934, L12870, L12739, all retired 9/30/2015 L12870 and related article (A25231).

Tracheotomy suction catheters, suction pumps, catheters and other related supplies/equipment:  Overpayments were previously identified where claims for pumps, suction catheters and related supplies/equipment were not in accordance with billing requirements outlined in the LCDs.

Group II support surfaces without correct diagnosis of condition: Documentation will be reviewed to determine if Group 2 support surfaces meet Medicare coverage criteria, meet applicable coding guidelines and/or are medically reasonable and necessary.

Osteogenesis stimulators: The RAC will review and deny claims for these items if they do not meet the indications of coverage and/or medical necessity guidelines in the LCD.

As always, please remember that The van Halem Group has both proactive and reactive RAC audit protection services available to suppliers and providers. Please contact us for more information at (404) 343-1815 or http://www.vanhalemgroup.com/contact-us.