codycalhoun25

Commander Marie Casey, Deputy Directory of CMS Audit Division, spoke frankly and directly with RAC Monitor, on Tuesday, August 4, 2009, about a couple of issues that had lately been expressed by numerous providers, after reports were published of remarks being produced at provider outreach sessions concerning when, what or perhaps if physician providers had been going to be audited by RACs throughout the permanent system.

Present on the call had been: Connie Leonard, Director from the CMS Division of Recovery Audit Operations; Commander Marie Casey, Deputy Director of that division; Howard Coan from the CMS Press Workplace; Chuck Buck, President/CEO of RAC Monitor; Patricia Dear, President/CEO of eduTrax; and myself. Pat Dear conducted the interview from some prepared questions, and Commander Casey graciously answered some followup concerns with candor and simple conversation.

Prior to the interview, Pat Dear spoke to numerous contacts and clients within the provider community, asking for input and guaging their anxieties and widely differing interpretations of the RAC system. If you had been going to speak with Commander Casey, what would you ask? If you’ve been reading RAC Monitor, it is not difficult for you to guess what the most typical question, which boils down to this: “How will this function?”

Will Physicians Face Take Backs?
Here will be the 1st question addressed to Cmdr. Casey:

“If a hospital is denied for any service or admission due to failing to meet ‘medical necessity’ as described by CMS, will the physician face take backs related to their orders for those denied services?”

Cmdr Casey replied, “We have posted that answer on our web site. A RAC might choose to look at those associated physician services as component of that inpatient remain. However, a review from the Component B services must also be preapproved by CMS, and will require additional records requests, from the other providers involved.”

So essentially, the brief answer is “Yes.” A much more complex answer, nevertheless, may be much more correct, albeit less satisfying, maybe. Following hearing Cmdr. Casey speak about this problem for a whilst, although, I did realize that the question itself is actually more complicated than 1 may think, and it does indeed deserve a much more complex answer.

1 needs to think about that an audit like this issues an inpatient admission, and such services fall below Medicare Component A, while the attendant physician services, even though related with an inpatient admission, fall under Medicare Part B.

Audits of Part A Services vs. Part B Services
When a RAC conducts an audit for medical necessity on an inpatient admission, it is necessarily a Complex Audit (which demands human evaluation of medical records), and also the review will probably be considering the Part A services only. Any associated Part B services are not necessarily approved to become below evaluation, in such a case.

So, while Part B services May be reviewed, such critiques need separate prior approval by CMS, and additional record requests. This is part of what Cmdr. Casey termed the “New Issue Evaluation Procedure.”

The New Problem Review Process
Cmdr Casey further explained that “the New Issue Review Procedure demands that the RAC submit a proposal for widespread evaluation in one or much more states. CMS then either (a) approves the problem as submitted for evaluation, (b) gives a conditional approval for review inside a smaller area, (c) gives a conditional approval with some caveats, or (d) declines to approve the problem as submitted. rac recovery audit contractors, rac audit, rac audits

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