Case Management

Mentor moment: CMS identifies common vulnerabilities, hints at medical necessity reviews

Case Management Weekly, July 21, 2010

CMS recently released a special edition MLN Matters article that provides information about vulnerabilities identified during the recovery audit contractor (RAC) demonstration. The information is an effort to prevent these same problems from happening in the future, according to CMS.

The two common vulnerabilities CMS identified during the RAC demonstration were:

  • Provider non-compliance with timely submission of requested medical documentation
  • Insufficient documentation that didn’t justify that services billed were covered, medically necessary, or correctly coded

CMS says providers must learn from the mistakes made during the demonstration program because of “the expansion of the RAC Program and the initiation of complex medical review (coding and medical necessity) in all four RAC regions.” This suggests that medical necessity reviews are coming soon.

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