Recipe for ne­ces­sity

Providers wary of de­lays from new RAC re­views

Modern Healthcare - - The Week In Healthcare - Jen­nifer Lubell

Health­care ex­perts are ques­tion­ing whether out­side au­di­tors for the Medi­care pro­gram are pre­pared to take on a new type of ad­vanced au­dit that ad­dresses a touchy and per­sonal sub­ject: the ne­ces­sity of a pa­tient’s care.

The CMS said it ap­proved the first “med­i­cal ne­ces­sity re­view” au­dits for the Re­cov­ery Au­dit Con­trac­tor pro­gram, open­ing the door to more po­ten­tial prob­lems for providers, who fear added de­lays and in­creased re­jec­tion of re­im­burse­ments. RAC third-party au­di­tors hired by the CMS get to keep 9% to 12.5% of provider pay­ments they iden­tify as im­proper.

So far, the agency has ap­proved 18 types of in­pa­tient hos­pi­tal claims and one type of durable med­i­cal equip­ment claim for med­i­cal ne­ces­sity re­views. As of now, “All of the RAC re­gions have some med­i­cal ne­ces­sity re­views ap­proved,” a CMS spokes­woman said. Med­i­cal ne­ces­sity re­views are likely to be­gin in the next cou­ple of weeks.

RACs pre­vi­ously had mainly been con­duct­ing au­to­mated au­dits, which are less-com­plex re­views that in­volve run­ning data queries and seek­ing im­me­di­ate claims de­nials, and com­plex re­views, which ask for med­i­cal records and the cod­ing of a spe­cific claim.

Med­i­cal ne­ces­sity re­views, though, delve into the ap­pro­pri­ate­ness of med­i­cal care given to a pa­tient, mean­ing they’ll re­quire more re­sources from hos­pi­tals and more dig­ging on be­half of the RAC pro­gram au­di­tors. The ad­di­tion of these re­views adds “an­other com­pli­cated bur­den to the RAC process,” said Karen Sch­midt, di­rec­tor of med­i­cal records for 777-bed Henry Ford Hos­pi­tal in Detroit. Hos­pi­tal clin­i­cians are al­ready pressed for time, and the med­i­cal ne­ces­sity re­view adds a cler­i­cal com­po­nent, where “the hos­pi­tal will have to co­or­di­nate with a physi­cian or care­giver in pre­par­ing an ap­peal” in the event the hos­pi­tal wants to chal­lenge the re­view, she said.

What con­cerns the Amer­i­can Hos­pi­tal As­so­ci­a­tion and oth­ers in the in­dus­try is that RAC au­di­tors may lack the nec­es­sary clin­i­cal and Medi­care knowl­edge to de­ter­mine whether prior hos­pi­tal care was rea­son­able, given the ex­pe­ri­ences of hos­pi­tals dur­ing the RAC pro­gram’s three-year demon­stra­tion project.

The AHA “con­tin­ues to have con­cerns about RACs be­ing paid on a con­tin­gency ba­sis to do med­i­cal ne­ces­sity re­views,” which caused more prob­lems dur­ing the demon­stra­tion project than any other type of au­dit, said Don May, the AHA’s vice pres­i­dent of pol­icy.

Sch­midt: Hos­pi­tal­physi­cian co­or­di­na­tion nec­es­sary for ap­peals.

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