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Coming soon: Recovery auditor prepayment reviews

Patient Access Weekly Advisor, June 27, 2012

Last November, CMS unveiled three demonstration projects aimed at reducing improper payments in the Medicare program. A few months later on February 3, 2012, CMS announced that it would be delaying two of the three of these demonstrations, one of which is the Recovery Auditor prepayment review demonstration.

Though the CMS website lists the start date as “Summer of 2012,” the delay—which came as a result of comments and concerns from providers— originally pushed the official launch to June 1, 2012. If we are, in fact, in the midst of the Recovery Auditor prepayment review demonstration, there has been no official announcement. Despite this fact, if providers have not already begun doing so, they should take action, according to Sharon Easterling, MHA, RHIA, CCS, CDIP, CEO of Recovery Analytics in Charlotte, N.C.

“With the shift of the RAC to up-front documentation review, providers should implement concurrent processes in their case management and utilization review areas,” she says. “From there, you should have second level review done by a physician for these particular DRGs.”

She continued, “Facilities may also want to consider educating their physicians on these particular DRGs to identify key documentation points that help to meet medical necessity.”

When it comes to physician education, all doctors are different, and some are more receptive than others. In situations where it requires a bit more effort, Easterling suggests using a physician advisor.

“Having a physician that speaks with the other physicians about the required documentation for medical necessity—and the translation of that information—is very important.”

Other staff members to consider when ramping up efforts against prepayment reviews are clinical documentation improvement (CDI) nurses and professionals. In some cases, patients come in with more than one condition, so assigning the correct DRG becomes imperative, so these CDI nurses and professionals should—in addition to staying up to date on CMS guidance related to the program—be involved in the process of concurrent review as well. In addition, coders should also be educated and confirm the order and patient type prior to billing, suggests Easterling.

Though it may surprise no one to hear it, providers need to make sure that medical records are as complete as possible before they go out the door. Make sure that the records do not have any signature issues, make sure that they have been pre-reviewed, and make sure that they contain all the necessary documentation; as these are the most important aspects of the record, explains Easterling.

In addition, she mentions, if providers see denials come into their facility as a result of these prepayment reviews, they should look into appealing that determination.

“Appeal, appeal, appeal; when you read that [the recent CMS update that came out on appeals], you tend to think that providers aren’t appealing enough,” she says. “Continue to appeal and work on documentation efforts.”

For more information on the prepayment review demonstration program, click here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.html

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