Connolly Continues to Post High-Dollar Issues for Review

eduTrax News Service - February 10, 2010.

Region C RAC Adds 19 New Issues

Connolly Healthcare, the RAC for Region C (south & southeastern states), posted 19 new approved issues for review on their RAC Issues page, on Monday, February 8, 2010. Following the format they have been using to date, the listed issues include only single MS-DRGs, but are still not listed in any particular order. All of the new issues are approved for DRG Validation, affecting all thirteen of the Region C states (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX).

Trend Continues: High-Dollar DRGs Reviewed

Of the 52 DRGs with Relative Weights of better than 5.0, Connolly just added four (4) more to their list. They now have eight (8) in their list to review. Also, six (6) of the 19 new issues are ranked (by number of discharges)  in the top 100 DRGs nationwide. Give their demonstrated proclivity to review high-dollar DRGs, these additions are not surprising, coming from Connolly.

Also: Three States Added

Notably, Arkansas, Lousiana and Mississippi were added to the states affected lists for all previously approved DRG Validation issues, now bringing them fully under the magnifying glass of the RAC. These three states were added to the posted DRG Validation issues on February 2.

Still No Medical Necessity Reviews

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 (PIM) itself, in Chapter 6.5.4. None of the RACs' posted issues are approved for review of Medical Necessity, to date. However, it is likely that the existing DRG Validation issues will all be approved for medical necessity review in short order, since the CMS RAC Review Phase-In Strategy allows for such approvals in calendar 2010.

Providers should keep in mind that when RACs receive records for review of DRG Validation, those same records can be reviewed for Medical necessity very easily. Therefore, the RACs will already have in hand many claims with all the records needed to perform medical necessity review. Indeed, it is highly likely that the RAC will already have conducted such a review, since it is inherent in any DRG Validation review, per the PIM. No additional documentation requests will be needed for those claims.

More Useful Lists Available

Many providers have expressed frustration at the lists being posted by the RACs. eduTrax providers more useful lists: to find links to all the RAC New Issues Pages here. For the more useful lists at eduTrax, see below.

Use the links below to see details of the newly posted issues, in our database (Editor’s Note: this list appears here in the reverse order as posted by Connolly):

Find a list of all their posted issues HERE.  (Registration required.)

The publications and documents mentioned above may be found in the eduTrax Documents section, HERE.