All RACs Approved for Complex Reviews
| All RACs Approved for Complex Reviews |
| Written by Team eduTrax |
| Thursday, 21 January 2010 00:00 |
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eduTrax News Service - January 21, 2010. DRG Coding and DRG Validations Approved for All Permanent RACsThe Centers for Medicare & Medicaid Services (CMS) approved all four of their Recovery Audit Contractors (RACs) to begin review of Medicare claims for Complex Review. The specific target areas for review, at this time, include DRG coding and DRG Validation. Medical Neccessity is not yet under review, despite the requirements stated by the Medicare Program Integrity Manual itself. ... Except for the most recent postings by CGI Federal, the RAC for Region B, responsible for reviews in seven (7) upper midwestern states, all DRG Validation issues posted by the RACs on their public webpages include the phrase, "Medical Necessity is excluded from review, at this time." This is consistent with the stated goals and strategy previously published by CMS. Medical Necessity reviews are likely not approved for CGI Federal, however, since this has not yet been approved for any of the others. Nevertheless, under the section that instructs CMS Contractors how to conduct DRG Validation reviews, medical necessity does seem to be required for such audits, as the following statement makes clear:
Despite the statements that this "issue" is not yet available for review by RACs, a records request for such an issue would in fact be identical to a records request for DRG Validation. Consequently, the RACs will already have all the records they need to create proposals to send to CMS for approval of medical necessity reviews. Also, since the RACs will already have many records in hand once the issue of medical necessity is approved, such reviews will no doubt produce an immediate flood of denials and additional records requests. The publications and documents mentioned above may be found in the eduTrax Documents section, HERE. |
| Last Updated on Thursday, 18 February 2010 00:12 |
