Needless to say, the past three weeks have been an interesting time in the health care arena. Today, in the third day of arguments before the Supreme Court, the question of whether the entire Patient Protection and Affordable Care Act should be thrown out if one section of the law is found to be unconstitutional will be debated. Two recent reports released by the OIG cast doubt on the effectiveness of the Medicaid Integrity Program. In such an environment, significant news on other fronts is easy to miss.

One such update came to the RAC world about two weeks ago that I now need to address, albeit in a tardy fashion.

Very quietly, CMS announced that as of March 15, the annual limit for documentation requests increased to 2% of all claims submitted in the prior year, divided by eight. This raised the maximum number of eligible requests for providers with less than $100 million in DRG claims to 400 every 45 days, from the previous limit of 300. For providers over that dollar mark, the limit has been increased from 500 to 600.

For the majority of the provider community, the sudden increase in records requests came as an unwelcome surprise. Whatever their sins with regard to the RAC program, CMS had been good up until now about telegraphing changes to the provider community. This particular announcement was released quietly on March 13th with an effective date of 48 hours after its release.

When we combine this change with the shift of demand letters from the RACs to the MACs, it’s time to call out CMS for attempting to game the system for better audit results. Knowing that the success rates of provider appeals remains sky-high, and knowing that 67% of what the RACs request in complex review leads nowhere, CMS had to adjust the house rules to their favor by making it harder for facilities to respond to the program. RAC coordinators nationwide, in addition to dealing with having to track down demand letters, have now seen their number of requests dramatically increase.

We are only 3 months into 2012, and the early returns for government audits are looking bleak, both for the contractors conducting audits and the facilities affected by their actions. This latest salvo by CMS is another in an ongoing attempt to justify the existence of audits by guaranteeing their success. It would be naive to think that this course correction by CMS will be their last attempt at changing the rules.

Tags: CMS / DRG / MAC / Medicaid Integrity Program / OIG / PPACA / RAC / Recovery Audit Contractors / supreme court
1:25 pm, March 28th, 2012 |