Health Information Management

News: CMS releases first quarter report regarding Recovery Audit Program

CDI Strategies, February 16, 2012

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CMS’ Recovery Auditors (previously called Recovery Audit Contractors, now associated with the Recovery Audit Program [RAP]), collected nearly $400 million in overpayments from October 1 through December 31, 2011, according to the Medicare FFS Recovery Audit Program FY 2012 first quarter report, released February 7.

The latest recoupment brings the RAP totals to nearly $1.3 billion collected in overpayments since the program’s inception in 2009, although the American Hospital Association contends that the amount may be much lower as the report does not account for appeal results. “Hospitals participating in the AHA's latest RACTrac survey report appealing about one in three claim denials, of which 73% were overturned on appeal,” AHA News Now reported on February 9.
 
According to the CMS report, top issues included:
  •  Diversified Collection Services (Region A) and Connolly, Inc. (Region C): Medical necessity for neurological disorders. “Medical documentation for patients with neurological disorders needs to be complete and support all services provided in the setting billed.”
  • CGI (Region B): Medical necessity for cardiovascular procedures. “Medical documentation for patients undergoing cardiovascular procedures needs to be complete and support all services provided in the setting billed.”
  •  HealthDataInsights, Inc. (Region D): Medical necessity for minor surgery and other treatment billed as inpatient: “When beneficiaries with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for less than 24 hours, they are considered outpatient for coverage purposes regardless of the hour they presented to the hospital, whether a bed was used, and whether they remained in the hospital after midnight.”



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