As we reach the Month of May, I can reflect on an April full of ups and downs.
On April 12th, my house in Milwaukee was burglarized. While on my way to work, two rank teenage amateurs smashed my son’s bedroom window, ransacked the house and took items that were mostly recovered the same day when the police in another district caught them. I have learned lessons about the attention spans of my neighbors, the price of getting a window boarded up on a Saturday and home owner’s insurance coverage. The mothers of these fine juveniles will soon receive a lesson in what we call “subrogation”.
Two days after the robbery, I found myself in Florida (one of the many lands of my nomadic youth) for this year’s AAPC National Conference. Being that it occurred in Orlando, my wife and son joined us for days at Disney World. I have thoughts to share on the slogan “Let the Memories Begin”, but I’ll hold those thoughts until later. The conference itself was one that was strangely productive as compared to those of the past.
More than anything else, as it applies to this recently-neglected space, April of 2013 became the month when the awareness of Medicaid RAC program reached critical mass. I have been a frequent guest on RACMonitor.com’s Monitor Monday RAC webinar/broadcast, and the number of questions regarding Medicaid RAC, as well as comments from affected facilities, has begun to pick up. In the interest of my entire reading population, I am going to share everything I have on Medicaid RACs right here, right now. There are still considerable gaps, so if you have any information to fill them, let me know.
Let’s begin by a little exercise in addition by subtraction. Despite the fact that the Medicaid RAC reviews were scheduled to begin nationwide on January 1, 2012, six states – Florida, Hawaii, Maryland, Oklahoma, South Dakota and Vermont – still lack a contractor. Half of these states have received what are called “time-limited exemptions” from the program, meaning that CMS’ patience for these states not having a contractor is finite.
I have no information, other than the name of the contractor, for 29 of the remaining states. For the 15 states below, information remains sketchy, but at least I have something:
Connecticut, Idaho & New York – HMS has been pursuing what they believe to be incorrect Medicaid Secondary payments for patients with Medicare as their primary insurance as part of automated review. Providers in these states who receive these repayment demands are urged to review each line item carefully, as there have been several errors in the reports that have crossed my desk.
Indiana – HMS has been going after DRGs for septicemia (416, 417, 584), OR procedures unrelated to diagnosis (468, 476, 477) Tracheostomy (482, 483, 700 with ICD-9 procedure codes 31.1 or 31.29) and claims featuring excisional debridement (procedure code 86.22). There also appears to be a focus taking shape on long term care claims, but these investigations have yet to fully emerge. Indiana providers are also urged to review each piece of Medicaid correspondence carefully, as it has been reported to me that it is somewhat problematic determining the difference between a Medicaid RAC request and one from the state’s fraud control unit.
Iowa – OptumInsight is casting a wide net. They are, at the least, currently reviewing hospital claims for stays over 2-3 days, elective c-sections, elective major bowel procedures, elective total joint replacements, spinal fusions, procedures of the uterine adnexa for non-malignancy, heart failure and shock. For the major bowel procedures, the focus appears to be falling on claims for stays of 6-9 days due to complications. Iowa Medicaid has become ruthlessly efficient in recouping funds, as they have developed a habit of doing so within 30 days of the denial letter, even if an appeal has been filed. It is also notable that Iowa offers no interest on appeals if found in the provider’s favor. Cry not, for they’ll always have ethanol as a companion boondoggle.
Kansas – HDI, a subsidiary of HMS, has been penalizing providers via automated review for patients who had an active Medicaid HMO at the time of service when straight Medicaid paid. What I have noted as “a variety of DRGs” are also being reviewed.
Michigan – I have received extensive information on Michigan’s Medicaid RAC program from two different sources in the last month. Due to an unforgiving schedule, I have yet to review the information that has been forwarded in great detail. I can tell you that HMS is looking at Medicare crossover claims for duplicate payment and overlapping inpatient stays with other facilities. Michigan has a unique request limit of a maximum of 150 records per request, not to exceed 500 records in a 3-month period.
North Carolina – HMS is extremely busy in the Tar Heel State (they must employ a larger-than-normal number of smokers). Beginning on March 1st, DRGs 191, 192, 292, 313 and 391 for short stays are under the microscope. Hospitals are warned that InterQual criteria is used for review. Ambulance claims have been on the hit list for over a year. HMS does appear to be dropping the ball on hospice claims for patients whose hospice services were billed to Medicare. HMS does not recognize that only nursing home room and board was billed as pass-through to Medicaid, which is leading to HMS reviewing the claims in question for “hospice eligibility”. North Carolina’s request limit is 300 records every 30 days.
Ohio – CGI is reviewing short stays for medical necessity. Ohio OB/GYNs are also on the radar, as CGI is reviewing low-level established E/M services billed at the same time as pre-natal care, particularly as it applies to the usage of the -TH modifier.
Oregon – HMS is looking at credit balance reports in the Beaver State.
Pennsylvania – HMS is looking at short stays for medical necessity on the hospital side in the Keystone State.
South Carolina – Following the pattern, HMS is looking at short stays for medical necessity in South Carolina. The request limit in the Palmetto State is 150 records every 30 days.
Tennessee – HMS appears to be subcontracting work out to their subsidiary, HDI. Claims for infusion services, inpatient medical necessity and DRGs 190, 191, 193, 392, 460, 743, 847 and 951 are on the radar. Watch the dates of the Medicaid RAC correspondence carefully, as there have been cases where payments are being recouped prior to providers receiving denial information.
Texas & Virginia – HMS is in both of these states, but issues have yet to be identified to me other than the fact that both states have no limit on records requests.
Again, if anyone can fill gaps in the information vacuum, I encourage you to do so. Additionally, if any of this information appears incorrect, by all means let me know.
Finally, I’d like to conclude with some quick thoughts on Walt Disney World. It did not escape my notice that upon every overpriced contrivance up for sale in the self-styled “Magic Kingdom” lay the phrase “Let the Memories Begin”. Even in a country dripping with commerce like the United States, the idea that someone has placed a price tag on the human memory should give us pause. The simplicity of life as it presents itself to all of us is not something that requires monetary outlay. It only demands that it be shared with someone close to you. It need not include worthless bric-a-brac stamped endlessly with animated mouse ears, but rather interaction on a human level, which is something that in the end money has no power to purchase.