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DRG 312 Reviews Put Providers 'In a Squeeze'

James Carroll, for HealthLeaders Media, October 2, 2012

"If you're in Ohio, you could potentially have your records requested by the MAC for a complex medical review, or you could have your records referred to the RAC [Recovery Auditor] for a prepayment review," she says. "This will put providers in a squeeze…the [CGS] error rate for DRG 312 is 79.9%."

She adds that providers can't do anything about what happened prior to the record requests aside from organizing those records, checking them for completeness, and sending them in. However, they can use the information and results moving forward to prepare for possible prepayment review.

Providers should take notice of this example and any others when it comes to high error rates found in postpayment claims audits and prepare themselves proactively to defend against prepayment reviews. If not, it will be like "shooting fish in a barrel" for the Recovery Auditors, suggests Beckley.

In addition, states that are not subject to the demonstration project should also take notice, even though it does not yet apply to them. Recovery Auditors are set to gain a lot of knowledge in terms of provider weaknesses and high denial rates, much like they did in the original [RAC] Demonstration Project, such as in the case of inpatient rehabilitation facility claims in California, according to Tanja Twist, director of patient financial services at Methodist Hospital of Southern California.

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