I have made a minor career out of being the keeper of a large amount of what I refer to as “bar knowledge”. For the uninitiated, bar knowledge is classified as those obscure facts which cause arguments in bars which are eventually solved by the least likely person in the bar, who usually doubles as the person with the most drinks consumed.

As an example, one of my oldest friends in the world is also an airline pilot. Based on his connection to me, the company for which he performs this task wishes to remain anonymous. He was on a two-day layover in San Francisco, which gave him an opportunity to enjoy the nightlife of the City by the Bay. My phone rings at about 10 PM (8 PM on the coast), and it’s my friend asking me to settle an argument.

“What was Traffic’s first album?”, he asked. Of course, I knew that the answer was Mr. Fantasy, which was Steve Winwood’s first record with someone other than the Spencer Davis Group (I almost digress). My friend won a free drink, and I returned to my television program.

Some people are geniuses, other people just know a lot thanks to numerous fateful intersections with information. I’m very much in the latter category, but I’m told I have a little more personality than the average genius. I’ve found that bar knowledge has a habit of enlightening people quickly, which is something genius simply cannot do. One of the greatest books ever written, A Brief History of Time by Stephen Hawking, takes years to digest based on the weight of its intellectual heft.

Knowing I’ll never be a genius is quite freeing actually, in that my mind is designed to read and retain minutiae most people find meaningless. For purposes of this space, I came across a great example while researching RAC requests.

For me, there is a big blank spot in the RAC process, and that can be formed as a simple question: what audit issues do the RACs want to look at that have yet to receive CMS’s widespread approval? When an issue is approved, the issue appears on the listings compiled on the websites of the four RAC contractors, but the RACs and CMS are not sharing information about what issues are under consideration for widespread audit.

In an e-mail response to my inquiry on the subject yesterday,  Scott Wakefield, the CMS Project Officer for RAC Regions A & B stated “The nature of any issue for widespread review may change significantly during Board review of the evidence provided by the RAC, therefore, the CMS New Issue Review Board does not publish a list of review issues pending approval”. While this is polite, concise government-speak that is covered more easily by the word “NO!”, there is a phrase in that answer that should catch your attention, and that phrase is “…evidence provided by the RAC…”. If an issue isn’t on the approved issues list, how is the RAC gaining evidence?

Exploring further, I found the following RAC FAQ on the CMS website: 

Question: I received an additional documentation request (ADR) letter from a Recovery Audit Contractors (RAC) for an issue that is not approved on their website.  Do I need to submit the record?

Answer: RACs may request a small sample of records to assist CMS in determining if an audit concept is consistent with Medicare policy and should be approved for widespread review. Providers must still submit the requested documentation to the RAC within the expected timeframe to avoid having that claim denied. The RAC will complete its review of the claim and issue a review results letter within 60 days.

Since I’m not a genius but rather a grand high exhalted keeper of bar knowledge, let me simplify this for you. The approved issues lists are nice, but the RACs can look at anything at any time if they identify a targeted claim as an issue they want approved. Clarifying further, respond to all additional documentation requests in a timely fashion, no matter what issue may be at stake!

If you take this information and combine it with information previously learned regarding what constitutes “good cause” for audit, and the conclusion that I reach is that every issue is on the table for RAC audit. This allows for the following scenario to happen. A RAC identifies an issue it believes should be approved for widespread review. It sends ADR’s to affected physicians and the review results show some aberrations, but not enough, in the view of the CMS New Issue Review Board, to approve the issue for widespread review. For the providers who are determined to have been overpaid based on the RAC testing their theories, one consolation is that the information is not forwarded to the administrative carrier for adjustment until CMS approves the issue for review. If the issue is not approved, a letter will be sent to the provider stating that the audit for the affected claims has been closed.

The last gap in my bar knowledge database has to do with issues for which widespread review is rejected based on the evidence furnished by the RAC. If pending approvals are not published, it would stand to reason that rejected issues are not published as well. Utilizing deductive reasoning, I would say that based on the scope of fraud previously identified in government health care, it would not be in CMS’ personality profile to inform providers of issues that are not being reviewed. To cover all my bases, Mr. Wakefield responded to my latest question on this issue, saying “No, rejected issues are not made public”. If a provider receives a letter stating that the audit has been closed, archive it and share the issue (PHI excluded) with anyone who will listen. This is how we’ll all learn what has not been approved.

The particular bar knowledge shared with you today isn’t as enticing as knowing album titles for info seekers on a bender in Frisco, but it’s hoped that it was just enough to illustrate the new reality of the RACs having the mandated ability to look at anything it wishes for any reason.

Tags: ADR / CMS / RAC / Recovery Audit Contractors
10:40 am, November 3rd, 2010 |