Since the RAC Demonstration Program launched in 2005 and the final RAC program launched in 2008, Wachler & Associates, P.C. has been instrumental in the effort to obtain full Part B outpatient reimbursement for hospitals where a short-stay inpatient claim has been denied for lack of medical necessity. Although our…
The Centers for Medicare and Medicaid Services (CMS) have announced a Special Open Door Forum on the Recovery Audit Prepayment Review Demonstration Program set to begin August 27, 2012. The Special Open Door Forum will be held August 9, 2012 from 2:00-4:00pm EST. Instructions and materials can be found on…
In the recently issued Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule for 2013, CMS is soliciting comments regarding policy changes that could be made on the issue of inpatient versus outpatient admission. (To view the CMS factsheet please click here.) CMS is seeking comments on potential changes which could…
CGI has added a new issue to its approved issues list for Region B: Outpatient Bevacizumab (Avastin) services: Bevacizumab (Avastin) represents 10mg per unit and should be billed one (1) unit for every 10mg per patient. Claims for J9035 should be submitted so that the billed units represent the administered…
On May 29, 2012, Connolly added new approved issues to its Approved Issues List for providers in Region C states. The new approved issues are across five categories and include: • Medical Necessity: Other O.R. Procedure of the Blood & Blood Forming Organs MS-DRG 802, 803, 804 W/MCC, W/CC, w/o…
On April 2, 2012 DCS Healthcare posted new approved issues to its approved issues list for some Region A states. Among them were two issues for skilled nursing facilities: · CT Scans, Head and Neck, Incorrect Billing: Potential incorrect billing of CT scans not supported by medical necessity (NGS LCD…
The Centers for Medicare and Medicaid Services (CMS) has announced that the Prior Authorization of Power Mobility Devices (PMDs) and the Recovery Audit Prepayment Review Demonstration Programs are expected to move forward on or after June 1, 2012. On December 30, 2011, the two demonstrations were delayed from their initial…
Recent Recovery Audit Contractor (RAC) activity demonstrates that the Centers for Medicare and Medicaid Services (CMS) may soon allow RACs to target skilled nursing facilities (SNFs) with certain levels of Ultra High Therapy Resource Utilization Groups (RUGs). Although Ultra High Therapy Resource Utilization Groups are not currently a CMS-approved audit…
The Centers for Medicare and Medicaid Services (CMS) published a proposed rule on November 5 regarding RAC activities for Medicaid programs. Section 6411 of the Patient Protection and Affordable Care Act (PPACA) requires states to contract with one or more Medicaid RACs by December 31, 2010. By that date, states…
In September the American Hospital Association (AHA) released its RACTrac for the second quarter of 2010. RACTrac is a nationwide survey conducted by the AHA which documents the ongoing Recovery Audit Contractor (RAC) activity. The purpose of the survey is to fill the void of information provided by the Centers…