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The RAConteur: A Positive Change (For A Change)

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

Subtle changes happen all around us every day. We blink, time has gone by, and we suddenly don’t recognize what has happened, unless the change leads to something very good or very bad. Everything in the middle tends to be piled one on top of the other until one day, nothing is familiar.

On April 1st, there was a small change implemented by Connolly Consulting, the Region C RAC regarding reported overpayments which I’m happy to say is positive, but is a harbinger of many steps to come.

Prior to the above date, when a review results letter was sent to a provider by Connolly, an overpayment amount was indicated. What providers were not aware of was that the amount indicated on the demand letter was only a projected recovery amount. It turns out that Connolly and the MAC contractors in Region C were not utilizing the same calculation tools to determine DRGs, which led to significant differences between the estimated amount on the demand letter from the RAC, and the actual recoupment amount from the MAC.

We’ve been told from the beginning of this process that the RACs were using proprietary software to identify improper payments. One wonders why CMS missed the important step of verifying that the dollar amounts from the RACs and the MACs matched.  

As of April 1st, to avoid confusion, Connolly is no longer placing a projected recovery amount on review results letters. For those providers not existing in Region C, I believe I have just opened up the following can of worms. Until it is verified that this practice isn’t happening in the other three RAC regions, I highly recommend that the amounts indicated on review results letters be compared to the amounts recouped by the MACs. Go forward on the assumption that the amounts determined by the RACs are estimates only, otherwise there is a very unpleasant pile of subtle surprises waiting for your provider at the end of the road.