Health Information Management

CMS addresses medical necessity reviews, RAC expansion in RAC 101 call

HIM Connection, May 18, 2010

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CMS representatives addressed two developing recovery audit contractor (RAC) areas during the May 5 RAC 101 conference call for DMEPOS—forthcoming medical necessity reviews and RAC program expansion to Part C and Medicaid.

Providers might see medical necessity reviews “within the next month or so,” according to Scott Wakefield of CMS. “We don’t have a specific timeframe for it but it will begin soon.”
 
This is the agency’s most specific statement yet regarding medical necessity. Previously CMS only mentioned that these reviews will begin within calendar year 2010. The DRG validation issues that the RACs are now auditing specifically exclude medical necessity.
 
CMS also provided some insight into the expansion of the RAC program under the recently enacted Patient Protection and Affordable Care Act. Although the provision is currently at the HHS departmental level and CMS policy-makers have not yet heard whether the plan is to move the existing RACs into the new areas, Wakefield said that “it doesn’t appear that they will.”
 
Editor’s note: Visit HCPro’s Revenue Cycle Institute for the latest RAC information.



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