BHM Appoints New Business Division Leader Kathleen Schoenauer

Posted on January 30, 2012 by Danyell Jones

Congratulations Kathleen Schoenauer

BHM Healthcare Solutions is excited to announce the appointment of Kathleen Schoenauer, RN, BSN, CCM, to the position of Business Division Leader. Ms. Schoenauer brings a wealth of leadership and project management knowledge to the organization, as well as a strong reputation for successful implementation of state-of-the-art solutions within the fast-paced health care industry.

Prior to joining BHM, Ms. Schoenauer enjoyed an impressive 12 year career with APS. During that time, Ms. Schoenauer was responsible for the financial and business performance of multiple products and contracts to both a government and commercial customer base. Additionally, she has experience in designing and delivering services and solutions through collaboration with Medicaid agencies, state and local governments, health plans, employers and labor trust groups. Ms. Schoenauer has consistently exceeded expectations when improving profitability, designing a suite of services and building strong management teams.

BHM is very excited have Ms. Schoenauer join the organization, and looks forward to the benefit its customers will receive from her many years of experience in medical and behavioral managed care, specifically including her expertise in disease management, utilization management , and case management. “Because of her consistent ability to develop and market innovative approaches to process improvement and problem solving, we feel that she will prove to be a great asset to both our organization and our clients,” commented Mark Rosenberg, CEO of BHM.

Upon appointment to her new position, Ms. Schoenauer stated: “I look forward to my new role at BHM Healthcare Solutions and working with the talented team at BHM in providing best practice solutions for our partner clients. BHM Healthcare Solutions is a forward-thinking organization, positioned for growth and continued success helping clients achieve their goals and implement successful healthcare programs.”

7 Lessons Learned from the Swine Flu

Posted on January 25, 2012 by Casey Roberts

As the H1N1 outbreak of 2009 taught us, we as a modern society are just as apt to be exposed to outbreaks, as well as the behavior that follows. Because the next outbreak is only a matter of time away from happening, we thought now would be a good time to go over some lessons learned to be applied to the next time. So without further ado, here are the seven things that swine flu taught us.

Public Health Emergency does not mean panic – Back in 2009 when the swine flu first hit the states, public officials were declaring an emergency after 20 people had infections confirmed. More people die per day of the flu than were diagnosed back then, which doesn’t necessarily merit a panic, but what if the next outbreak is more serious?
There is tons of medication – In fact, when the outbreak hit in 2009, there was a supply of 50 million units of anti-viral drugs that could have been used immediately, not to mention a pharmaceutical industry that was prepared to make lots more.
Planning pays – There was a system in place for the case of an outbreak that did include mobilizing the proper people. There were also plans in place that were implemented to stockpile medicines should an outbreak occur.
The media helped – Although the media can be blamed for over-exaggerating or under-exaggerating outbreaks, it is also a vital part of relaying information. Just about every private citizen heard about the outbreak, its symptoms, and what to do from the media.
Rise of outbreak sites – In addition to the CDC’s site that lists outbreaks and updates, there were also other sites that sprang up to meet the need of people who wanted to be notified immediately of outbreaks. There are sites such as FluTracker and Outbreak Alert that can tell you what has been reported in your area.
Review – The outbreak of swine flu was also a good chance for everyone to brush up on good hygiene and safety practices like washing your hands, covering your mouth, and not going into work if you think you’re contagious.
More vaccine plants – The outbreak of 2009 showed how limited the United States’ own resources were limited. In fact, Time reported that only one plant in Pennsylvania produced flu vaccines in the U.S.

Casey Roberts is a student and also writes for Radiology Assistant which helps students find the right radiology degree.

Please Welcome Guest Poster Casey Roberts

Posted on January 25, 2012 by Danyell Jones

Hello everyone,

I just wanted to take a quick moment to introduce our guest poster, Casey Roberts. Casey has wonderful information about timely healthcare topics, we hope that you will enjoy these posts and welcome Casey to our online blog community.

Cheers!

Compliance and Employee Buy-In

Posted on January 24, 2012 by Kathleen Rand

Healthcare Compliance is daunting but necessary

Under the Affordable Care Act, compliance programs have become mandatory. To have an effective compliance and ethics program, according to the ACA, an organization “shall (1) exercise due diligence to prevent and detect criminal conduct; and (2) otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.

Compliance officers are stepping up their efforts to evaluate compliance effectiveness in light of the health reform law’s mandate, which will make programs a condition of Medicare and Medicaid participation, and the HHS Office of Inspector General’s Medicare compliance reviews, which include hospital compliance programs.

With the government looking over their shoulders, theses compliance officers are trying to find the best ways to reduce risk in their organizations through processes, and to demonstrate that risk has been reduced through outcomes. An effective compliance program encompasses seven fundamental components: policies and procedures; management oversight; education and training; and reporting; enforcement and discipline; auditing and monitoring; and remedy and corrective action. However, the pivotal factor in any program is employee buy-in and behavior.

Compliance programs can have solid structure and well-defined process which covers the principles of acceptable compliance such as discrimination and harassment, confidentiality, reporting illegal or unethical behavior, and licensing and professional credentialing. Yet, even mature compliance programs have a long way to go in the effectiveness-evaluation department, according to compliance officers, who are starting to look outside the box for ways to determine their impact on the organization.

Design is good, but organizations need to know what difference is being made, and if an impact is being made on employee behavior and the organization’s culture. A compliance program should have full integration, not just focus on specific areas. Additionally, another step would be valuable in the compliance model: a measurement of the change created.

For example, an error is identified and fixed, and a corrective action plan is implemented and reported to the board. But did it change anyone’s behavior? Is anyone monitoring the corrective action plan? If the error recurs, is a root cause analysis conducted to find out why behavior didn’t change? Most people in the compliance world do auditing/monitoring and corrective action plans, but accountability regarding the change mage would go a long way in strengthening compliance programs.

Furthermore, employee behavior is a significant indicator of buy-in and overall compliance program effectiveness. The goal is for employees to call the compliance office before there’s a problem, for their awareness to increase. Culturally, it is so important for compliance to permeate as a value.

HIPAA Security Explored

Posted on January 21, 2012 by Kathleen Rand

A significant provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Department of Health and Human Services (HHS) to adopt national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. To date, the implementation of HIPAA standards has increased the use of electronic data interchange. The Affordable Care Act of 2010 will further these increases and include requirements that will be necessary to adopt. In addition, health plans will be required to certify their compliance. The Act provides for substantial penalties for failures to certify or comply with the new standards and operating rules.

Given the above stipulations, we are going to explore the some issues pertaining to HIPAA computer and technology security.

One of the first steps is to understand why computer security in healthcare is so important. It seems rather rhetorical: the answer is because everyone cares about the privacy and integrity of their health information. In most cases, the point of computer security is to prevent personal health information from falling into the wrong hands or being inadvertently altered or destroyed.

The HIPAA security standards apply to protected health information (PHI) that is either stored or transmitted electronically. PHI is health information in any form that personally identifies a patient.

Computers have made the issue of identity much more problematic. People have always been able to use someone else’s identity for criminal purposes, but the problem is aggravated when we can’t use physical means to confirm their identity. How do you know the person whose name is attached to an electronic health record (EHR) entry really made it? It’s difficult. The bottom line is this: Computer security is needed to protect the privacy of those whose information that is stored and managed. It is also needed to protect an organization from the risk of penalty and legal liability if private information is used or released.

The HIPAA security standards require healthcare organizations to have written security policies and procedures, including those that cover personnel training and sanctions for security policy violations. Your office staff and colleagues must truly understand basic security logic and take their role in protecting patients’ privacy very seriously.

The HIPAA security standards require your practice to appoint someone as the security manager, so you might want to assign these tasks to that person. Furthermore, an organization must also understand what encryption will do and when it is necessary. Contrary to what many people are saying, the HIPAA security standards do not require e-mails, or any other transmission from a doctor’s office, to be encrypted. The standards do require your practice to assess whether its unencrypted transmissions of health information are at risk of being accessed by unauthorized entities.

Encryption is the transformation of a message from plain text into nonsensical cipher text before the message is sent. Anyone who steals the cipher text message will not be able to understand it. Only those who have the code used to encrypt the message can convert it back from cipher to plain text and reveal its meaning.

For several reasons, encryption is generally not employed for information stored on a computer’s hard disk or transferred within an office’s local area network. First, the risk of disclosure to unauthorized parties is small in the closed environment. Second, encrypting data is costly. Third, encryption generally slows down the movement of information within software applications and databases.

The HIPAA security standards require an organization to obtain assurances from business associates that they will implement the necessary safeguards to protect the confidentiality, integrity and availability of the electronic health information they create, maintain or transmit on behalf of the organization.

Remember that there is no one-size-fits-all approach for computer security. What counts is being “reasonable and appropriate” when matching security measures with the level of risk that pertains to an organization’s situation.

Ten HIPAA Questions Answered

Posted on January 18, 2012 by Kathleen Rand

In this blog, we will review ten questions about the Health Insurance Portability and Accountability Act, or HIPAA. The legislation can seem overwhelming; sometimes breaking it down can make it much easier to digest.

Of course to ensure that your organization is prepared to overcome any compliance roadblock, please consult BHM regarding our HIPAA Compliance analysis: click here for more information

HIPAA ensures a 'lock' on privacy.

1. What is HIPAA?

The Health Insurance Portability and Accountability Act, or HIPAA, was passed by the federal government in 1996. The original intention of HIPAA

was to help guarantee the continuation of health insurance coverage when an individual left his or her job. Additionally, HIPAA was expanded to include a number of provisions in order to simplify and lower the costs of processing health information. A number of these provisions deal with the standardization of electronic transactions, particularly regarding security and privacy issues.

2. What is the HIPAA Security Rule?

HIPAA requires the implementation of security standards to help protect health information. Yet, it does not spell out any specific security requirements. HIPAA simply necessitates administrative, technical and physical safeguards to make sure that the integrity of health information remains confidential. These requirements have been defined and published in the HIPAA Security Rule by the Department of Health and Human Services.

4. What type of information is protected by HIPAA?

Health information is defined as any information, whether spoken or recorded in any form, that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or healthcare clearinghouse. This information can be related to the past, present or future physical or mental health condition of an individual, the delivery of health care to an individual, or the past, present or future payment for the provision of healthcare to an individual.

5. Who must comply with the HIPAA Security Rule?

Any Health Plan, Health Care Clearinghouse or a Health Care Provider who transmits health information in electronic form must comply with the HIPAA Security Rule. A Health Plan is defined as an individual or group plan that provides or pays the cost of medical care. A Health Care Clearinghouse is defined as a public or private entity, including a billing service, re-pricing company, community health management information system or community health information system that does either of the following functions: (1) Processes health information received from another entity in a nonstandard format; or (2) Receives a standard transaction from another entity and processes health information into nonstandard format for the receiving entity. A Health Care Provider is defined as a provider of services, a provider of medical or health services and any other person or organization who delivers, bills or is paid for health care in the normal course of business.

6. What are the repercussions of non-compliance with HIPAA?

Failure to comply with HIPAA requirements could result in significant financial loss through civil penalties, not to mention damage to an organization’s reputation. HIPAA states that civil penalties up to $100 per day per person can be issued for non-compliance. While this does not seem like a large sum, it can quickly add up. For instance, if student health information was exposed for 1000 students over the course of 30 days, the fines could reach $3,000,000.

7. May a physician or hospital “fax” a patient’s medical information to other physicians or to an insurer?

Yes. The Privacy Rules do not prohibit a “covered entity” from faxing protected health information. A physician should be sure, however, to comply with the Privacy Rules’ requirements for disclosures generally. For example, the physician should check whether the “minimum necessary” rule applies and, if it does, limit the information in the fax to the minimum necessary information.

Also, a physician should be sure to have appropriate security safeguards in place that are administrative, technical, and physical in nature. For example, the physician should use policies and procedures that require office staff to verify the recipient’s fax number and use a cover sheet that does not include protected health information.

8. What is the “minimum necessary” standard?

HIPAA requires a physician to make reasonable efforts to limit the amount of protected health information that the physician uses or discloses to the minimum amount that is necessary to accomplish the purpose of the use or disclosure.

Importantly, this requirement does not apply when a physician discloses information to another provider for treatment purposes or when a physician requests information from another provider for treatment purposes. Accordingly, the minimum necessary standard should not interfere with a physician’s ability to provide appropriate treatment to patients.

9. May a physician discuss information about a patient’s treatment with other physicians using e-mail or fax?

Yes. Physicians may use any method of communication — including e-mail, oral conversations, written letters, or other methods (including sending facsimiles) — so long as the physician uses “reasonable and appropriate safeguards” to protect the communication. HIPAA does not prohibit a covered entity from emailing or faxing protected health information to a physician.

If a covered entity refers to the Privacy Rules as the reason the individual will not fax information to a physician, the physician may direct the covered entity to the Department of Health and Human Services’ Frequently Asked Questions at: http://www.hhs.gov/ocr/privacy/hipaa/faq/index.html. The physician may also assure the individual that appropriate safeguards are in place to receive the fax securely.

10. If a patient’s family members call to ask how their loved one is doing, what can the treating physician disclose?

HIPAA allows a physician to share a patient’s information with the patient’s family member or friend if the information is limited to what is directly relevant to that person’s involvement in the patient’s care. For example, a physician may tell a person living with the patient that the patient needs plenty of rest and lots of fluids or that the patient needs to take a prescribed medication twice daily with food. The physician should not share more information than the person needs to assist with the patient’s care.

A physician should not share a patient’s information with the patient’s family or friends if the patient has asked the physician not to, or if the physician believes, in his/her professional judgment, a disclosure would be inappropriate.

RAC Learning Series Part Four – Demystifying the Query (Audit) Process

Posted on January 17, 2012 by Vickie Axsom Brown

Demystifying the Query (Audit) Process

Vickie Axsom-Brown, Senior Consultant, BHM Healthcare Solutions

BHM assists organizations mitigate RAC audit risk

Demystifying the Query Development process is key to every health care provider’s success regardless of the type of services delivered. It requires an understanding of the resources, references and tools used by RACs so providers can maintain their organization’s preparation for CMS audit “participation.”

The tools used by RACs are vast and may look like alphabet soup. The “New Issue” process begins with the responsible team’s identification of potential billing/reimbursement issues. The typical “New Issues” team is comprised of experienced claims’ processing representatives with Part A, Part B, DME, pharmacy, home health, hospice, hospitals, providers, SNFs, et. al. specific backgrounds. This team uses their experience and multiple resources to identify potential issues for which analysis will be done to validate issue value.

In addition to experience, the following data sources are used (the alphabet soup):

Raw Data – RAC database, routine CMS RAC Data Warehouse downloads, industry trends…
Outcome Reports – CERTs[i], OIG[ii], PEPPER[iii], GAO[iv], QIOs[v]….
Industry Experience[vi] & Information – AAHAM, AHA, AMA, AAASC, JCAHO, JCAHACO…
Policy/Rules and Regulations[vii] – LCDs, NCDs, CRs[viii], IOMs, MLN…
CMS Programs – ZPICS[ix], DOJ[x], Vulnerabilities Reports[xi], Carriers, FIs, MACs

Information is collected and evaluated to determine potential improper payment trends, type of provider(s) involved, resources and financial impacts, and projected outcomes. Data are analyzed by statisticians and/or SAS analysts to define the each of these elements by targeted provider type(s). Once analytical results are provided to the New Issue team, the list of improper payments is prioritized and the New Issue submission type/preparation begins.

Different submission criteria exist for New Issue automated reviews (examples of findings and results required) and New Issue complex reviews (medical record documentation and evaluation findings required). The RACs preparation and submission processes vary due to CMS Review Board supportive information/analytical requirements and can range from 30 to 120 days preparation prior to RAC submission to CMS.

All New Issues require complete data presentation with projected Medicare Trust Fund returns. The CMS New Issues submission package is well-defined and must meet all specifications before presentation to the CMS Review Board. If a New Issue package fails any defined criterion, it is returned to the RAC for re-submission. This means the RAC loses a place in line for the CMS Review Board’s review/approval of a New Issue. 2010, the CMS New Issues Review Board had an ever-increasing New Issues backlogs resulting in their encouragement that all RACs collaborate on a list of New Issues for Board consideration. RACs pursued the recommendation and drafted eight (8) New Issues for collaborative submission to the CMS Review Board.

Upon receipt of a New Issue package, designated CMS Review Board representative(s), review(s) the package for submission compliance, content, New Issue review type (automated/complex), value (financial returns), and review submission direction. The New Issue package may be presented to the RAC Validation Contractor for assessment and recommendations and/or to the CMS Review Board (physicians, policy makers, et. al.). Once reviewed, the CMS Board generates a decision:

1- Approved as submitted.

2- Approved with modifications.

3- Approved with defined limitations.

4- Denied for current review period, resubmit in one year.

5- Denied.

Approved New Issues are posted on the RACs’ provider portals and are available for the RACs inclusion in future audits.

[i] Comprehensive Error Rate Testing (CERT) Program reports (www.cms.gov/CERT/CR/LIST.asp. Lists reports by hear and Report Type, e.g., Over utilized codes, CERT findings, Use corrective actions to monitor improper payment findings. This website usually accessible from Carrier/FI/MAC Website link.

[ii] Office of Inspector General Reports (www.hhs.gov/reports.asp

[iii] Program for Evaluating Payment Patterns Electronic Report (PEPPER); Published by TMF Health Quality Initiative under contract with CMS…Audio on demand for Pepper information; PEPPER 2011: Identify Changes, Address Vulnerabilities and Be Audit-Ready

[iv] General Accounting Office “GAO” Reports (www.gpoaccess.gov)

[v] Quality Improvement Organization Reports, www.cms.gov/QualityImprovementOrgs/

[vi] Inpatient, Ambulatory, Outpatient, DME, SNF, CORF, Rehab, Hospice, Physician, et.al.; www.beckerhospitalreview.com; high risk coding errors, duplicate claims, pricing errors, billing excessive units, failure to meet LOC requirements, payment errors, SNF consolidated billing, cross over coverage (ambulance, medications, ), questionable level of care, improper diagnosis codes, mismatched codes, et.al.

[vii] Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) www.cms.gov/medicare-coverage-database/

[viii] CMS Change Requests www.cms.gov/Transmittals/downloads

[ix] Zone Program Integrity contractor – ZPICs (former Program Safeguard Contractors) www.zpicaudit.com

[x] Department of Justice, www.justice.gov/oig/reports/index.htm

[xi] Vulnerability Reports (multiple references); www.gao.gov – Spotlight or Key Issues section or www.gao.gov/docsearch/repandtest.html

NAMCP/AAMCN Survey Reveals Costs and Concerns of Primary Care Coordination

Posted on January 6, 2012 by Danyell Jones

The Journal of Managed Care Medicine which is published by the National Association of Managed Care Physicians has long been an outstanding resource for industry providers, and Vol. 14 No. 4, published in 2011 was no different featuring a timely article which focused on the integration of Behavioral Health into a Primary Care Setting. The article is focused upon a survey conducted by the National Association of Managed Care Physicians (NAMCP) in coordination with the American Association of Managed Care Nurses (AAMCN) which sought to determine how members of these organizations gauged the importance of Behavioral Health Care in the overall treatment of patients.

Click on the Graphic Above to Read this Article and More in the Current Issue

“As healthcare continues to change, and physicians become more and more aware of the mind-body approach to patient treatment, integration of Behavioral and Primary Healthcare will become preeminent in importance. At BHM Healthcare Solutions this is one of our guiding focuses when concentrating on assisting organizations with their clinical operations. We understand that the goal of every provider is the provision of superior care, but the financial aspect of Behavioral Health/Primary Care Integration was often cited as a stumbling block. The recent survey conducted by NAMCP is encouraging with the results showing that providers of care appreciate how costs can escalate when there is a behavioral health co-morbidity present with a primary health issue, underscoring the need for impactful coordination to not only ensure optimal care, but decrease overall healthcare costs” stated Danyell Jones.

Dr. Mark Rosenberg, President of BHM Healthcare Solutions and author of the recent article has often assisted organizations guiding them toward an integrated approach to healthcare. Additionally, Dr. Rosenberg has delivered several notable presentations and learning series around the country at national conventions focused on this topic. “Behavioral Health integration is one of the most substantial things an organization can do to ensure quality improvement in healthcare ” states Dr. Rosenberg, who went on to say that “one of the most important aspects of behavioral health consulting is ensuring that integration becomes part of every organizations healthcare management strategies.”

For more information on BHM Healthcare Solutions services please visit our quality improvement page

RAC Learning Series Part Two – New RAC Statement of Work

Posted on January 5, 2012 by Vickie Axsom Brown

RAC ALERT

NEW RAC STATEMENT OF WORK

BHM assists organizations prepare for RAC audits

Vickie Axsom-Brown, Senior Consultant, BHM Healthcare Solutions

In the recent year a Centers for Medicare & Medicaid Services (CMS) Cms.hhs.gov- Recovery Audit Contractor Update was generated. The new update was the 090111 Recovery Audit Program Final SOW [PDF, 292 KB] (an updated State of Work for the Recovery Auditors). Several key areas were revised, updated and/or clarified. A summary of these include:

Recovery Audit Contractors revised to Recovery Auditors.
Additions and Clarifications that the Recovery Audit Program includes ALL contracts, all types of claims with the focus being on lower error rates and identifying improper payments with the greatest impact on the Trust Fund to prevent misunderstandings. Medicaid RAC documents have referred to Medicare Recovery Auditor focus limitations as acute care facilities.
Addition of a new type of review – “semi-automated review” a new 2 part review process which can include both automated and complex reviews. This review type does not pay providers for medical record submissions.
Clarification of DRG Validation versus Clinical Validation by adding definitions.
Addition of language for “Allowance for a Discussion Period” to clarify this process – e.g., an escalation process for the discussion period, where a physician (or a physician employed by the provider) may request to speak to the Recovery Auditor physician and new directives that once an appeal is filed with the MAC, the discussion period must be discontinued. This minimizes duplications of effort by the Recovery Auditor and MAC.
Change to the Recovery Auditor website’s listing of new issues whereas the new issue list must be sortable by a minimum provider type by June 1, 2011.
Addition that CMS reserves the right to share new issues with all CMS review entities. (Collaboration)
Clarification of Recovery Auditors and MACs roles.
Addition of Recovery Auditor activities when CMS refers potential improper payment notices (Technical Direction Letter) to them.
Further clarification on the Adjustment Process as it relates to associated findings.

More information to follow….

[i] Medicaid RAC FAQ, Question 13, “You stated that the scope of the Medicaid RACs must be “broad”. Can you expand on this?”

RAC Learning Series Part One – RAC Statement of Work

Posted on January 3, 2012 by Vickie Axsom Brown

RAC ALERT

NEW RAC STATEMENT OF WORK

BHM provides key 'survival" preparation for RAC audits

Vickie Axsom-Brown, Senior Consultant, BHM Healthcare Solutions

Recently, a Centers for Medicare & Medicaid Services (CMS) Cms.hhs.gov- Recovery Audit Contractor Update was generated. The new update was the 090111 Recovery Audit Program Final SOW [PDF, 292 KB] (an updated State of Work for the Recovery Auditors). The following areas were updated:

Page 1 – Recovery Audit Contractor Program changed to Recovery Audit Program with contractors called “Recovery Auditors.”
Page 1 – Addition – “The CMS expects Recovery Auditors to review all claim types to assist the Agency in lowering the error rate and in identifying improper payments that have the greatest impact on the Trust Fund.”
Page 1 – Addition – “…review of all claim and provider types and a review of claims/providers that have a high propensity for error based on the CERT program and other CMS analysis.”
Page 6 – Addition (collaboration for program improvements) – “The Recovery Auditors will identify and report LCDs that can benefit from central office evaluation and identify their characteristics (out of date, technically flawed, ambiguous, and/or superficial). Identification of these LCDs will improve the integrity of the Medicare program and the performance of the Recovery Auditor program.”
Page 7 – Additional clarification to address large organizations who have multi-sited locations across Recovery Auditors – “Unless otherwise directed by CMS through technical direction, the claims being analyzed for this award will be all fee-for-service claims processed in Region ___ regardless of the providers’ or suppliers’ physical locations. Exception: Claims processed by the legacy fiscal intermediary Wisconsin Physician Services (WPS) will be subject to review exclusively by the Recovery Auditor with jurisdiction over the provider’s physical location.”
Pages 8-9 Improper Payments INCLUDED in the State of Work include the list of provider types to eliminate misunderstandings. Medicaid RAC documents have referred to Medicare Recovery Auditor focus limitations as acute care facilities. [i]
Page 20 – New Review Type – “Through ‘semi-automated review’ which entails an automated review using claims data and potential human review of a medical record or other documentation.”
Page 22 – “Semi-Automated Review is a two-part review. The first part is the identification of a billing aberrancy through an automated review using claims data. This aberrancy has high indexes of suspicion to be an improper payment. The second part includes a Notification Letter that is sent to the provider explaining the potential billing error that is identified. The letter also indicates that the provider has 45 days to submit documentation to support the original billing. If the provider decides not to submit documentation, or if the documentation provided does not support the way the claim was billed, the claim will be sent to the Medicare claims processing contractor for adjustment and a demand letter will be issued. However, if the submitted documentation does support the billing of the claim, the claim will not be sent for adjustment and the provider will be notified that the review has been closed. This type of review is to be used in which a clear CMS policy does not exist but in most instances the items and services as billed would be clinically unlikely or not consistent with evidence-based medical literature.
Page 22 – “The Recovery Auditor is not required to reimburse providers for the additional documentation submitted for semi-automated reviews.”
Page 23 – Section Addition – “DRG Validation vs. Clinical Validation – DRG Validation is the process of reviewing physician documentation and determining whether the correct codes, and sequencing were applied to the billing of the claim; Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented.

[i] Medicaid RAC FAQ, Question 13, “You stated that the scope of the Medicaid RACs must be “broad”. Can you expand on this?”