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CMS postpones RAC complex reviews of medical necessity until 2010

HIM Connection, June 9, 2009

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CMS anticipates Recovery Audit Contractor (RAC) automated reviews will begin in late June and July, according to Marie Casey, deputy director of the Division of Recovery Audit Operations at CMS. However, this is not set in stone, she says, noting, "there is some leeway."

But complex reviews won't begin until later, says Casey. CMS is aiming to begin certain types of complex reviews (e.g., coding and DRG validation) this fall. However medical necessity complex reviews won't begin until early 2010.

The nature of automated reviews is simpler on the whole, she says, making them an easier choice to roll out first. "The automated reviews are less burdensome on the provider, because there's no request for medical records," says Casey, adding that automated reviews are also easier on the RACs themselves to manage.

The further delay of medical necessity auditing is due to the sheer complexity of the reviews. "We’re delaying because it’s more difficult. We are really trying to ensure that when there is a difference of opinion [on the medical necessity determination of the case], the RAC clearly documents their rationale," says Casey.

Casey says the delay will also help CMS with the rollout of its "issue review team," a group comprised of members of various agency divisions that will look at questions that come in about policy (e.g., whether the RACs are correct in interpretation of coding guidelines). The issue review teams will be looking comprehensively at the questions, with staff with varying expertise on the review team, before approving new issues for RAC review, according to CMS Representative Kathleen Wallace, who spoke during a May 28 Region D RAC training session held in Helena, MT.

For more analysis, visit HCPro’s Web site.

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