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Recovery Auditor Prepayment Review Demos Imminent

James Carroll, for HealthLeaders Media, August 10, 2012


Diving further into possible target areas, CMS extracted a number of short-stay DRGs from data in the CERT report that present billing problems for providers. These DRGs represent the first group of DRGs that will be held for prepayment reviews. CMS previously announced the schedule for 2012 reviews:

 

  • January 1: MS-DRG 312, syncope and collapse
  • March 1: MS-DRG 069, transient ischemia and MS-DRG 377, gastrointestinal (GI) hemorrhage with MCC
  • May 1: MS-DRG 378, GI hemorrhage with CC and MS-DRG 379, hemorrhage without a CC or MCC
  • July 1: MS-DRG 637, diabetes with MCC, MS-DRG 638, diabetes with CC, and MS-DRG 639, diabetes without a CC or MCC

Operational details
As previously stated, this program will not replace ongoing MAC prepayment reviews, but will serve as a separate entity that aims to help lower the error rate. Providers will not be subject to review for the same topic or issue by two different contractors, according to CMS.

Speaking from experience, Yvonne Focke, RN, BSN, MBA, director of revenue cycle integrity at Kentucky's St. Elizabeth Healthcare, says that prepayment reviews, of which she has received 186 this year from her MAC (CGS), place an added burden on providers.

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