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New OIG and RAC Review Topics

Published on 

Monday, October 30, 2017

 | Quality 
 | OIG 
 | Recovery Auditor 

I once illustrated the myriad of Medicare contractors and affiliates that perform pre-payment and/or post-payment medical reviews as a spider’s web – a day late for a Halloween connection. There are at least a couple of reasons supporting an association between the two. First, healthcare providers would never want to be caught in the “web” of reviews (especially if the spider proves to be the cause of their demise).  And secondly, as the filaments of a spider’s web connect together, there are connections between the different Medicare auditors.  Medicare Administrative Contractors (MACs) may review problematic issues identified by the Comprehensive Error Rate Testing program (CERT).  MACs may refer at-risk issues to other reviewers such as the Recovery Auditors (RACs) or the RACs might refer topics back to the MACs.  The MACs or RACs may follow-up on overpayment issues identified by the Office of Inspector General (OIG) or the OIG may further investigate inappropriate payment issues identified by the MACs or RACs. This month’s report on new RAC and OIG review issues are perfect examples of this inter-related web of reviews.

There has not been a lot of new issues approved for Recovery Audit Contractor (RAC) reviews in the last month.  HMS, the Region 4 Recovery Auditor, appears to have reposted some issues such as the complex review of medical necessity of sacral neurostimulation for outpatient hospitals.  HMS also added an automated review for critical access hospital (CAH) and outpatient hospital services on October 6, 2017 – Outpatient Services Overlapping or During an Inpatient Stay.  This review topic may be the result of findings of a recent report from the Office of Inspector General (OIG), which was addressed in detail in a Wednesday@One article from August. This automated issue is not yet listed on either the Cotiviti or Performant websites. There were no other newly approved issues related to hospital services for any of the RACs.

Hospital related issues have also been rare in the new updates to the OIG Work Plan the past few months.  In the October updates, there is one issue that affects hospitals.  The OIG will be reviewing supporting documentation to determine whether bariatric services meet the conditions for coverage and are supported in accordance with Federal requirements (Social Security Act, §§ 1815(a) and 1833(e)) and in keeping with the CMS National Coverage Determination (NCD) 100.1.  Medicare Parts A and B only cover certain bariatric procedures when the patient meets the following criteria:

  • a body mass index of 35 or higher,
  • at least one comorbidity related to obesity, and
  • had previously unsuccessful medical treatment for obesity.

Treatments for obesity alone are not covered. A CERT special study of bariatric surgical procedures found that approximately 98 percent of improper payments lacked sufficient documentation to support the procedures.  This issue was highlighted in the July 2014 Medicare Quarterly Provider Compliance newsletter.

So even though these are new posted issues for these contractors, they are issues we have seen before.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.