Continuing its efforts to publicize valuable information derived from the RAC demonstration, CMS released on December 2 the fourth in a series of MLN Matters articles.
The latest, Special Edition article SE1036, provides education on two high-risk vulnerabilities for physician claims. According to CMS, these claims were denied because the demonstration RACs determined that either a duplicate claim was billed and paid, or the physician reported an incorrect number of units for current procedural terminology (CPT) code billed based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy. Examples include:
Other services with excessive units—Units billed exceeded the number of units per day based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy. (Pre-appeal improper payment amount: $6,635,558)
Duplicate Claims—Physician billed and was paid for two claims for the same beneficiary, for the same date of service, same CPT code, and same physician. (Pre-appeal improper payment amount: $1,094,751
What these issues are in actuality—which CMS is not directly stating—are medically unlikely edits (MUEs), which should come as no surprise, according to Elizabeth Lamkin, MHA,president of Dalzell Consulting Group, Inc., in Hilton Head, SC.
"During the demonstration project RACs were very sensitive to physician providers and other small providers, and RAC auditors at this time were also very clear about medically unlikely edits, which is what we see here."
In the case of medically unlikely edits, physician offices, as well as any other type of provider organization, should be able to take notice of these issues prior to receiving a demand letter.
"Physician offices need to be proactively self-auditing their billing process and actively monitoring the RAC websites for medically unlikely edits such as IV hydration, fulvestrant—dose vs. billed units, and so on," says Lamkin. "Issues involving MUEs are often times clerical errors though, so this is an issue that can be avoided with comprehensive review."
While the two vulnerabilities described in SE1036 apply to duplicate payments and services with excessive units, it's clear that RACs and MACs may eventually choose to target physicians for other vulnerabilities as well, according to Michael Taylor, MD, vice president of clinical operations at Executive Health Resources in Newtown Square, PA.
"A clear vulnerability—although not listed in SE1036—involves cases where the physician billing does not match the hospital's billing status," he says. "For instance, when the physician's billing is for an inpatient level of care but the hospital bills for an outpatient observation service. This would be a simple, clear-cut reason for a RAC or MAC to audit and potentially deny cases when the billing is incongruent."
While physicians have not been a primary audit target to date; anything can change in the ever-shifting world of RACs, according to Lamkin.
"Physicians are going to be the next big target for the RACs," she says. "When they do automated reviews, there's no differentiation between provider types, so this is something that physicians are going to have to get their arms around."
To read SE1036, click here. The other articles in the series include:
James Carroll is associate editor for the HCPro Revenue Cycle Institute.