Home Health & Hospice Week

It's official, providers in RAC regions across the country now know what 'issues' the RAC auditors in their area are looking for.

Diversified Collection Services (DCS) of Livermore, Calif., posted several issues that are on its radar for Region A, which includes Connecticut, Delaware, District of Columbia, Maine, Massachusetts,New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

Region A Overview: All posted issues pertain to durable medical equipment (DME). They include wheelchair bundling and urological bundling (which should be familiar to you if you've been following Regions C and D), as well as pharmacy supply and dispensing fees.

Relevant HCPCS codes include Q0511 and Q0512. If a supply or dispensing fee is billed, there should be a corresponding oral anti-cancer, oral antiemetic, immunosuppressive drug or inhalation drug that is reimbursed on the same date of service (not denied), the site explains.

Bonus: DCS also posted a tool that every DME supplier can use. Every issue listed includes links to relevant CMS transmittals -- so no need to fumble around on the Centers for Medicare & Medicaid ServicesWeb site for reference materials, which is just about as much fun as dropping a bowling ball on your foot.

The issues list from CGI Technologies and Solutions Inc. of Fairfax, Va. was slightly different for Region B, which consists of Indiana, Michigan, Minnesota, Illinois, Kentucky, Ohio, and Wisconsin.

Region B Overview: CGI's posted issues included outpatient and physician billing issues involving blood transfusions, IV-hydration, and bronchoscopy services.

Tip: Region B's site appears stripped down and unhelpful at first glance, but don't worry. Just click on the live link for each issue and you'll access several handy explanations and transmittal links.

So now you know the RAC issues, but why invite trouble? Why not lay low and see if the RACs come to us, right? Wrong -- very wrong, corrects Nashville health care attorney Anna Grizzle with Bass Berry & Sims.

Once you know the targets, do self-assessments to discover whether your organization has had any of the billing problems under RAC scrutiny, and return any overpayments you find, Grizzle advises.

Why be proactive? "The data mining RACs can do is very sophisticated," Grizzle explains, "so if there is a systemic problem, they're going to find it" -- and they're going to tell other payers and regulatory agencies all about it.

Your action plan for self-assessment depends on your organization's size and resources, Grizzle continues. Generally, you want to pick a random sample of claims that reflect the RAC's announced issue. If you see "vulnerabilities" in those claims, you should investigate the problem further.

If you confirm there has been a systemic problem, work with your MAC to figure out a plan for returning overpayments, Grizzle says.

Think about what would be best for your organization -- reviewing each individual claim involved (very time-intensive) or doing a statistically valid sample and extrapolating the overpayment amount from there.

Resources: Read DCS' issues at www.dcsrac.com/issues.html and CGI's issues at http://racb.cgi.com/Issues.aspx?st=1.